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the initial assessment phase. pected outcome (e.g., “Resolved”) and revises the plan to include In this instance, assessment is the data collection form we use to the new nursing diagnosis with its appropriate expected outcome measure patient progress. and nursing actions. Continue indicates that the expected outcome has not been met. The nurse again collects the appropriate data and, based on the Data Collection data, makes the nursing judgment that the expected outcome has Initially, specific data should be collected to measure the progress not been met. She records the data and adds the phrase, “Continue, made toward achieving the stated expected outcome. As an example, reevaluate on [date].” She then modifies the plan of care by going let us return to the outcome written for Mr. Kit, the 19-year-old col- back to the stated expected outcome, marking one line through the lege student who had an appendectomy. The expected outcome was, date, and adding a new date. Likewise, the nursing actions would “Will have decrease in number of requests for analgesics by 11/3.” It be modified as necessary. is now 11/3, and the nurse caring for Mr. Kit notes the date and ini- With evaluation, the nursing process cycle is completed (Fig. tiates evaluation of the stated outcome. She first checks the chart and 1–1). Another cycle can begin with both the nurse and the patient counts the number of complaints of pain, number of analgesics given, being sure that quality care is being given and received. and Mr. Kit’s response to the pain medication. She looks for any change in medication or a change in Mr. Kit’s condition. She then in- Nursing Process and terviews Mr. Kit regarding his perception of pain acuity and level of Conceptual Frameworks relief. At the same time, the nurse completes other assessments, such as observing the wound condition and the ease of ambulation or not- NURSING MODELS ing the presence of any other untoward signs or symptoms. The nurse then studies the data to see what action is necessary. Many nurses do not see a direct relationship between nursing mod- els (nursing theories) and nursing process, but a direct relationship does exist. Nursing models present a systematic method for assess- Action Following Data Collection ing and directing nursing practice through promoting organization and integration of what is known about human health, illness, and Action following data collection simply means making a nursing nursing. Nursing models are based on purposeful orientations21; judgment of what modifications in the plan of care are needed. therefore, the nursing process is the action phase of a nursing model. There are essentially only three judgments that can be made: In essence, models guide the use of the nursing process,22 and, as 1. Resolved previously stated, the care planning presented in this book is a re- 2. Revise sult of the nursing process. 3. Continue For further clarification, let us look at a few examples. If you are a supporter of Levine’s Conservation Model, you would assess Resolved means that the evaluative data indicate the health care your patient in keeping with this model and then design your care problem reflected in the nursing diagnosis and its accompanying plan to reflect prioritizing of the nursing diagnoses and nursing ac- expected outcome no longer exist; that is, the expected outcome tions in a manner that would best promote conservation principles. Copyright © 2002 F.A. Davis Company 10 INTRODUCTION Assessment 1. Functional patterns: The functional patterns are client strengths that can be used to deal with either dysfunctional or potentially dysfunctional patterns; for example, Assessment of the Coping–Stress Tolerance Pattern shows no problem areas. Diagnosis The nurse can then use this functional pattern to assist the pa- tient in learning to cope with the identified problem areas. 2. Dysfunctional patterns: The Dysfunctional Health Patterns identify problem areas and the nursing diagnoses related to each Planning problem area; for example, in assessing the Elimination Pattern, the nurse identified problems with urination and specifically with Urinary Retention. Knowing that the patient has effective individual coping, the nurse then plans teaching that will utilize Implementation this strength rather than interventions that are totally nursing fo- cused such as intermittent catheterization. The nurse could teach the patient to use Credé’s maneuver, pouring warm water over the genital area, running tap water, and so on to use the Evaluation client’s already demonstrated strength. 3. Potential dysfunctional patterns: The Potential Dysfunctional Patterns are risk conditions; for example, a client who has uri- nary retention is at risk for the development of Excess Fluid Vol- ume. Utilizing this knowledge, the nurse would identify areas of FIG. 1–1. Nursing process flowchart. observation to monitor and to teach the patient to monitor. Use of the Functional Health Patterns in assessment stresses fo- cus on a nursing model of assessment, diagnosis, planning, inter- Likewise, if you are a proponent of Roy’s Adaptation Model, vention, and evaluation rather than a medical model. Thus, the you would assess the four adaptation modes, and then prioritize your nurse can readily differentiate between areas for independent nurs- diagnoses in an order that would best promote adaptive responses. ing intervention and areas requiring collaboration or referral. In summation, current nursing models affect care planning in terms Table 1–3 lists the Functional Health Patterns along with a brief of assessment and prioritizing of nursing diagnoses rather than re- description of each pattern as designed by Gordon.23 The titles of quiring different diagnostic statements and different nursing actions. the patterns are, in essence, self-explanatory. Because the titles are self-explanatory, the Functional Health Patterns are easy to use. The PATTERNS chapters in this book are organized using the Functional Health Patterns and each chapter includes more detail regarding each Several typologies have emerged as a result of the work done with functional health pattern as introductory information for the spe- nursing diagnosis. The typologies are representative of another step cific chapter. in theory development and are designed to facilitate the use of nurs- ing diagnosis. The typologies provide an organizational framework Human Response Patterns that enables the nurse to focus on the pattern description and as- sessment rather than trying to remember all the details of individ- Patterns of Unitary Persons were first presented at the Fourth National ual diagnoses. The nurse can easily locate the individual diagnoses Conference of NANDA. A group of nursing theorists met in between, by being familiar with the patterns. as well as during, conferences to design a framework for classification of nursing diagnoses.24,25 The NANDA Taxonomy Committee and Functional Health Patterns Special Interest Group on Taxonomy26 reviewed, clarified, and rela- beled the patterns as Human Response Patterns. These revisions Gordon1 writes that the Functional Health Patterns were identified, were presented at the Fifth and Sixth National Conferences. The pat- circa 1974, to assist in the teaching of assessment and diagnosis at terns proposed by the theorist group describe clustering factors that Boston College School of Nursing. The Functional Health Patterns represent person-environment interaction.27 The Unitary Persons organize the individual diagnoses into categories, thus providing categories were not mutually exclusive; that is, one nursing diagnosis for the organized collection of assessment data. might relate to one, two, or even three of the patterns. From the Fifth The advantages offered by assessment according to the Func- through the Ninth National Conferences, refinement of the Human tional Health Patterns include having a standardized method that Response Patterns has continued. At the Seventh National Conference does not have to be relearned if the setting, patient’s age, or condi- the Human Response Patterns were presented as the framework for tion changes; having an assessment tool specifically designed to NANDA Nursing Diagnosis Taxonomy I,28 and the taxonomy was en- lead to identification of pertinent nursing diagnoses; and having an dorsed by NANDA members attending this conference. To assist in assessment method that is holistic in nature.1 applying this typology, each diagnosis has information regarding its Functional Health Patterns focus on the client’s usual ways of liv- category and coding place in the Human Response Pattern. ing1 and direct attention to all the factors that impact the individ- This endorsement indicated acceptance of the Taxonomy I as a ual in these ways of living. Gordon1 defines a pattern as “a sequence working document that would require further testing, revision, re- of behavior across time.” The Functional Health Patterns allow the finement, and expansion. Additional input regarding Taxonomy I nurse to assess these behaviors by promoting the patient’s describ- Revised was solicited at the Eighth National Conference. Much of ing his or her own perception as well as incorporating the nurse’s the discussion at the Eighth Conference focused on the various lev- observations. Both the patient’s description and the nurse’s obser- els of the taxonomy with specific questions of the clinical useful- vations must be included to ensure a complete assessment. ness of level I. Use of the Functional Health Patterns for assessment allows iden- The first level of abstraction in Taxonomy I is the Human Re- tification of three major types of data: sponse Patterns. The second level is alterations in functions. Levels Copyright © 2002 F.A. Davis Company NURSING PROCESS AND CONCEPTUAL FRAMEWORKS 11 TABLE 1–3. FUNCTIONAL HEALTH PATTERNS PATTERN DESCRIPTION Health Perception–Health Management The patient’s awareness of personal health and well-being; health practices; understanding of how health practices contribute to health status Nutritional-Metabolic The patient’s description of food and fluid intake; relationship of intake to metabolic needs; includes indicators of ineffectual nutrition on metabolic functioning, for example, healing Elimination Description of all routes and routines of output; includes any aids to excretion Activity-Exercise Patient’s overall activities of daily living, including recreational activity Sleep-Rest Patient’s 24-h routine of rest, relaxation, and sleep Cognitive-Perceptual Cognitive functional performance and sensory performance Self-Perception and Self-Concept Patient’s self-assessment; attitudes, ability, worth; verbal and nonverbal communication Role-Relationship Patient’s assessment of all roles, related responsibilities, and interrelatedness between these factors and other people Sexuality-Reproductive Satisfaction-dissatisfaction with sexuality; any dysfunction in sexuality or reproduction Coping-Stress Tolerance Effectiveness or noneffectiveness in dealing with difficult situations; how handles; reaction to; support available Value-Belief Ideas held in esteem by patient; guiding principles for overall lifestyle Source: From Gordon, M: Manual of Nursing Diagnosis. 1995–1996. McGraw-Hill, New York, 1995, p 2, with permission. II through V become increasingly concrete, with levels IV and V re- concerns regarding the ease of use of Taxonomy I Revised and the un- flecting the diagnostic labels. Table 1–4 lists the Human Response clear classification of diagnoses into the taxonomic patterns. Patterns with accompanying brief definitions. In this book we have After reviewing multiple taxonomic structures, the Taxonomy focused on level II and include levels IV and V in the conceptual in- Committee voted to use an adaptation of Marjorie Gordon’s Func- formation and “Have You Selected the Correct Diagnosis?” sections. tional Health Patterns (FHP) as the basic taxonomic structure for Taxonomy II. The Taxonomy Committee received permission from Diagnostic Divisions: Taxonomy II Dr. Gordon and her publishers to adapt and use the FHP. Table 1–5 demonstrates this new structure. Following the Twelfth NANDA Conference, the Taxonomy Commit- At the Thirteenth Conference, the proposed Taxonomy II was pre- tee initiated work on Taxonomy II. NANDA members had expressed sented for members’ review and discussion. Additionally, members Image/Text rights unavailable Copyright © 2002 F.A. Davis Company 12 INTRODUCTION Image/Text rights unavailable Copyright © 2002 F.A. Davis Company VALUE PLANNING OF CARE AND CARE PLANS 13 Image/Text rights unavailable attending the conference participated in a Q-sort project. This pro- Valuing Planning of Care and Care Plans ject requested the participants to sort the individual nursing diag- noses into the proposed classes and served to validate diagnosis The nursing process and the resultant plan for nursing care have placement. not been given the attention or credit that they deserve. Part of the Subsequent to the Thirteenth Conference, the Taxonomy Com- problem is that planned nursing care has not had value attached to mittee continued to work on the refinement of Taxonomy II. At the it. All of us will make time or a place for those things that are of Fourteenth Conference held in April 2000, Taxonomy II was pre- sented to the NANDA membership for further consideration. The NANDA Board of Directors approved Taxonomy II following the Fourteenth Conference and additional revision by the Taxonomy

Committee. A unique feature of Taxonomy II is the use of axes. The use of axes simplifies wording structure of the diagnoses, allows a broader use of diagnostic terminology, is more clinically expressive, and promotes inclusion of nursing diagnoses into computerized data- bases. The proposed axes are illustrated in Table 1–6. To illustrate the use of the multiaxial structure, this example is provided. A client is assessed at a clinic. The client is a 15-year- old who is 5 ft 2 in tall and weighs 190 lb. The nurse decides the applicable diagnostic concept (Axis 1) is Nutrition. She then Image/Text rights unavailable chooses a modifier from Axis 6—“Altered” and “More than Body Requirements.” The nurse does not add “Adolescent” from the Development Stage Axis (Axis 4) because further assessment documents that the client’s entire family (brother, mother, and father) are also above standard weights for their age and height. Therefore, she selects “Family” from Axis 3 (Unit of Care). Because the problem is currently present, the nurse selects “Ac- tual” from the Potentiality Axis (Axis 5). The diagnostic statement then becomes: Actual Altered Nutrition, More than Body Re- quirements by a Family. Stating the diagnostic statement in this fashion promotes intervention for the whole family, which, in turn, increases the probability of successful intervention for the individual patient. Copyright © 2002 F.A. Davis Company 14 INTRODUCTION value to us. It is only recently that completing and evaluating the began to implement patient care. One nursing order read, “Change quality of care planning has begun to show up on employee evalu- dressing as needed.” Assessment of the dressing showed a change ation forms. Likewise, it is still rare to see “complete nursing care was needed. In the patient’s room were all kinds of dressings, flu- plan” or “update care plan” on the patient assignment form. ids, and ointments. There were no instructions for changing the With the changes that are occurring in health care, due to fed- dressing on the care plan or the patient’s chart. The nurse then re- eral and state legislated mandates, completion and use of nursing quested information from the patient who stated, “I don’t like to care planning is going to increase in importance. Several insurance look at it, so I don’t know.” The nurse then began to search for a companies now audit charts, care plans, and the like in detail. No staff member who had cared for this patient and could teach her the documentation of care means no reimbursement for care. Likewise, routine for the special dressing change. After 30 minutes, she finally one of the first places a lawyer looks when hunting evidence for found a nurse who had cared for the patient. Learning the proper health-related court cases is the patient’s chart. The basic principle dressing change took only a few minutes. The nurse then went back in lawsuits has been “not charted, not done.” Planning care as we to the care plan, and in 3 minutes recorded the way to change the propose in this book would furnish additional documentation that dressing under nursing orders. reasonably prudent care was given as well as providing a guideline Comparing the time it took to locate the information and the time for better charting. it took to record the information gives a graphic example of how time Use of nursing diagnosis helps ensure that teaching and dis- can be saved by completing and documenting the nursing process. charge planning are considered from the start of care. As we in- Consider the time saved if the written nursing actions are used as an crease our knowledge and begin to think in terms related to nurs- outline for charting, or the time that could be saved in between shift ing nomenclature, nursing actions for many of the diagnoses will reports if documentation of the nursing process was complete. Lastly, relate to teaching and planning for home care. consider the time that could be saved by not having to go to court Many of the standards supported by JCAHO, the ANA, and state when questions arise over reasonable prudent care. Making time to boards of nursing are automatically implemented when the nursing use and document the nursing process because we can see its value process is completed, implemented, and documented. A review of to us actually saves us time in the long run. these standards by the reader will show that the nursing process and careful planning of care can meet several standards just by writ- ing a nursing care plan. Summary It is not uncommon to hear, “I don’t do care plans because I don’t The nursing process provides a strong framework that gives direc- have time to do them.” It is true that there is an investment of time tion to the practice of nursing. By completing each phase, you can in completing and documenting the nursing process, but in the reassure yourself that you are providing quality, individualized care long-range view, such planning of care actually saves time. To il- that meets local, state, and national standards. By using the NANDA lustrate, one nurse, known to the authors, works full time in nurs- nomenclature and by providing feedback to NANDA, you can help ing education but works part time at a local hospital to keep her develop this nomenclature and help ensure that nursing is recog- clinical skills current. One afternoon she went to work at the hos- nized for the contributions it makes to our nation’s health. pital, received her patient assignments and a brief report, and then Copyright © 2002 F.A. Davis Company CHAPTER 2 Health Perception– Health Management Pattern 1. ENERGY FIELD, 6. LATEX ALLERGY RESPONSE, RISK FOR DISTURBED 21 AND ACTUAL 51 2. HEALTH MAINTENANCE, 7. MANAGEMENT OF THERAPEUTIC INEFFECTIVE 27 REGIMEN, EFFECTIVE 57 3. HEALTH-SEEKING BEHAVIORS 8. MANAGEMENT OF THERAPEUTIC (SPECIFY) 33 REGIMEN (INDIVIDUAL, FAMILY, 4. INFECTION, RISK FOR 37 COMMUNITY), INEFFECTIVE 61 5. INJURY, RISK FOR 42 9. PERIOPERATIVE-POSITIONING A. Suffocation, Risk for INJURY, RISK FOR 71 B. Poisoning, Risk for 10. PROTECTION, INEFFECTIVE 75 C. Trauma, Risk for 11. SURGICAL RECOVERY, DELAYED 81 Pattern Description a. Yes b. No (Risk for Injury) Nurses assist individuals, families, and communities who have lim- 4. Was the patient and family satisfied with the usual health status? ited knowledge or understanding of: a. Yes b. No (Health-Seeking Behavior; Ineffective Health Maintenance) 1. Their current health status 5. Did the patient, family, or community describe the usual health 2. How to achieve a good health status status as good? 3. How to maintain a good health status a. Yes b. No (Health-Seeking Behavior; Ineffective Health Maintenance) This lack of perception (awareness) leads to problems for the in- 6. Had the patient, family, or community sought any health care dividual or family in management (control) of their health status. assistance in the past year? The nursing diagnoses in this pattern are the results of this lack of a. Yes (Health-Seeking Behavior) perception and management. b. No (Ineffective Health Maintenance) 7. Did the patient or family follow the routine the (doctor, nurse, Pattern Assessment dentist, etc.) prescribed? a. Yes (Effective Management of Therapeutic Regimen) 1. Review the patient’s vital signs. Is the temperature within nor- b. No (Noncompliance, Ineffective Management of Therapeutic mal limits? Regimen) a. Yes 8. Did the patient or family have any accidents or injuries in the b. No (Risk for Infection; Ineffective Protection) past year? 2. Review the results of the complete blood cell (CBC) count. Are a. Yes (Risk for Injury) the cell counts within normal limits? b. No a. Yes 9. Is there a disruption (change in temperature, color, field, move- b. No (Risk for Infection; Ineffective Protection) ment, or sound) of the flow of energy surrounding the person? 3. Review sensory status (sight, hearing, touch, smell, and taste). Is a. Yes (Disturbed Energy Field) the patient’s sensory status within normal limits? b. No 15 Copyright © 2002 F.A. Davis Company 16 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN 10. Was the patient, family, or community able to meet therapeu- of nursing diagnoses for communities requires nurses to also de- tic needs of all members? velop interventions to influence health policy and to work with ad- a. Yes (Effective Management of Therapeutic Regimen [Indi- vocacy groups.2 vidual, Family, Community]) The Health Belief Model3 (Fig. 2–1) provides a framework in b. No (Ineffective Management of Therapeutic Regimen [Indi- which to study actions taken by individuals to avoid illness. A ba- vidual, Family, Community]) sic assumption of the model is that the subjective state of the indi- 11. Is the patient scheduled for surgery or has he or she recently vidual is more important in determining actions than is the objec- undergone surgery? tive reality of the situation. The Health Belief Model states that for a. Yes (Risk for Perioperative-Positioning Injury) an individual to take action to avoid a disease, she or he needs to b. No believe the following: 12. Does the patient exhibit eczema? a. Yes (Latex Allergy Response) 1. That she or he is personally susceptible to disease. b. No 2. That the occurrence of the disease will have at least a moderate 13. Does the patient have a history of multiple surgeries or of re- impact on some part of her or his life. action to latex? 3. That taking action will be beneficial. a. Yes (Risk for Latex Allergy Response) 4. That such action will not involve overcoming psychological bar- b. No riers such as cost, pain, or embarrassment. 14. Is the patient’s surgical incision healing properly? These beliefs can be described as variables under the headings of a. Yes “perceived susceptibility” and “severity” and as the variables that b. No (Delayed Surgical Recovery) define perceived benefits and barriers to taking action. Because these variables do not account for the activation of the behavior, the Conceptual Information originators of the Health Belief Model have added another class of variable called “cues to action.” The individual’s level of readiness A person who practices health management techniques, for exam- provides the energy to act, and the perception of benefits provides ple, exercises regularly, pays attention to diet, and maintains a bal- a preferred manner of action that offers the path of least resistance. ance of rest and activity; has an accurate view of his or her, or his A cue to action is required to set off this appropriate action. or her family’s, personal health status; and will also identify other The model suggests that by manipulating any combination of vari- ways to maintain health. These people will be accurate in reporting ables affecting action, the inclination to seek preventive care can be their current health status. They also will readily identify alterations altered. (changes) in health status and will take active steps to correct these The Health Belief Model does not contain concepts related to changes to increase their movement toward optimal health. Addi- knowledge of disease as a potential factor in determining an indi- tionally, they will also initiate measures to prevent further alter- vidual’s decision to engage in preventive behavior. Several authors ations in health status. The goal in health management is to assist point out that knowledge of health consequences has only a limited all patients to achieve this level of health maintenance. relationship to the occurrence of the desired health behavior.4–6 Various factors influence a person’s ability to achieve optimal Yet, quite often, imparting knowledge about diseases to the patient, health perception (understanding) and health management (con- in an effort to encourage future preventive behavior, is the main trol). Human beings are described by Martha Rogers as energy method used by nurses. fields.1 Disturbance in these fields can produce symptoms. Another The Health Belief Model is disease specific. The model does not major factor affecting health is individual and/or family interaction adequately explain positive health actions designed to maximize with the environment.1 This interaction increases the likelihood that wellness, fulfillment, and self-actualization. Although the Health environmental hazards will play a role in health management by in- Belief Model is useful in predicting preventive behavior, it does not creasing exposure to problem areas. Health protection activities can fully explain behavior motivated by health promotion.7 More re- reduce environmental hazards and increase optimal health manage- search is needed to identify the determinants of

health-promoting ment. Examples of such activities include individual and commu- behavior to increase our ability to assist the patient in achieving nity efforts to clean up air pollution, ensure a safe water supply, and health promotion. Preventing energy field disturbances, for exam- manage sewage and hazardous waste disposal. ple, is an area of research appropriate to nursing practice. Another major factor is an intact sensory system. Sensory organs The Health Belief Model does provide the nurse with the con- provide information to the individual regarding the environment. ceptual notion that by working with the patient’s perception of the An intact nervous system is also required, because it provides for situation, increasing the patient’s cues to action, and decreasing the optimum functioning of sensory, motor, and cognitive activities. patient’s barriers to action, the nurse can enhance the possibility An accurate cognitive-perceptual pattern and self-perception–self- that the patient will engage in disease prevention and early detec- concept pattern are also necessary to achieve the optimal level of tion activities. health perception and management. The ability to think and un- Pender7 points out that although health promotion and disease derstand greatly impacts basic knowledge of health and illness. prevention are complementary concepts, they are not congruent Likewise, the individual’s feeling of self-worth and interpretation of (identical). Health promotion is directed toward growth and im- the meaning of health and illness to the self influences his or her provement in well-being, whereas disease prevention conceptually health practices. Knowledge related to health promotion and dis- operates to maintain the status quo.8 ease prevention is essential for the individual to fully maintain The Health Promotion Model as developed by Pender7 (Fig. 2–2) health management. provides the framework for nursing research and practice. This Cultural, societal, and familial values and beliefs also influence model emphasizes the importance of cognitive-perceptual factors the capacity to achieve positive health perception and health man- in behavior regulation. Cognitive-perceptual factors—for example, agement. Values and beliefs influence what is identified as optimal understanding of the importance of health, understanding of the health. Availability of appropriate health care resources in a com- definition of health, perceived self-competency, and perceived con- munity impacts the health care delivery system and the ability of trol of health—are primary motivational mechanisms for health- the community to manage a therapeutic regimen. The development promoting behavior. Copyright © 2002 F.A. Davis Company CONCEPTUAL INFORMATION 17 Image/Text rights unavailable Individual Characteristic Behavior-Specific Participation in and Experiences Cognitions and Affect Behavioral Outcomes Perceived benefit of action Perceived barriers to action Immediate competing demands (low control) and preferences (high control) Prior related behavior Perceived self-efficacy Activity-related affect Commitment Health to a promoting Personal factors: plan of action behavior Biologic Psychological Interpersonal influences: Sociocultural Family, peers, providers Norms, support, models Situational influences: Options Demand characteristics Aesthetics FIG. 2–2. Health Promotion Model. (From Pender, NJ: Health Promotion in Nursing Practice, ed 3. Appleton-Century-Crofts, Stamford, CT, 1996, p 58, with permission.) Copyright © 2002 F.A. Davis Company 18 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Healthy People 20109 describes the national health promotion 1. Adhere to medical and nursing treatments and disease prevention objectives. Two major goals are addressed: 2. Make lifestyle changes necessitated by condition 3. Seek consultation from experts in area requiring intervention, 1. Increase quality and years of healthy life for example, individual practitioners and support groups 2. Eliminate health disparities The document presents baseline epidemiologic data and projected Developmental Considerations goals for health promotion, health protection, and preventive ser- vices. Special emphasis is placed on vulnerable populations, for ex- Care providers can encourage the acceptance of responsibility for ample, those in lower socioeconomic status, the disabled, the elderly, health-promoting activities and adherence to agreed-on treatment and certain ethnic groups. This document is recommended as a guide plans by giving appropriate attention to the impact developmental for identifying factors that influence the health perception–health levels have on the individual or the primary caregiver. Publications management pattern. Strategies for intervention and evaluation are such as Prevention Across the Life Span14 and Put Prevention into Prac- also included. tice10 can assist the nurse, patient, family, and community to estab- Whether working with individuals, families, or communities, the lish a routine of health-promoting behaviors and practices. nurse should plan interventions appropriate for the learning needs of those being targeted. Mass-media campaigns are useful when conveying general information to large groups of people, but one- INFANT AND TODDLER to-one communication is more effective for instructing individuals Because the neonate is totally dependent on others for care, it is the in their particular circumstances. Put Prevention into Practice10 is a primary caregiver who is entrusted with carrying out the therapeutic comprehensive system developed to assist the clinician and the pa- interventions. As the infant grows and develops, self-care abilities in- tient and his or her family to establish a routine of preventive be- crease. The following information outlines developmental milestones haviors and services. The kit includes a clinician’s handbook, pre- from birth to approximately 24 months as described by Piaget’s sen- ventive care timelines, office reminders, and patient-oriented sorimotor stage of cognitive development.15 During this period of de- materials to promote preventive behaviors. velopment, the individual must be protected from hazards in the en- The concepts of primary, secondary, and tertiary prevention11 vironment, and the primary caregiver must assume the major share are also useful to the nurse when using the health management pat- of responsibility for compliance with the treatment program. tern. It is important for the nurse to recognize that a focus on the Providing a safe environment includes the following accident patient’s strengths, not just the patient’s problems, is an integral prevention strategies: (1) turning pot handles away from edge of part of health promotion.12,13 stove; (2) storing medicines, matches, alcohol, plastic bags, and Primary prevention consists of activities that prevent a disease house and garden chemicals in child-proofed areas; (3) using cold- from occurring. A patient engaged in primary prevention activities water, not hot-water, humidifier; (4) avoiding heating formula in would: microwave; (5) using protection screens on heaters, fireplaces, and electrical outlets; (6) using nonflammable clothing; (7) gating stair- 1. Maintain up-to-date immunizations ways and windows; (8) supervising children at play, while bathing, 2. Have adequate water supply and sanitation facilities in car, or in shopping cart; (9) controlling pets or stray animals; 3. Use seat belts and infant car seats and properly store household (10) avoiding items hung around neck; (11) providing a smoke-free poisons to minimize accident fatalities environment; (12) avoiding small objects that can be inserted in 4. Eliminate tobacco products mouth or nose; (13) avoiding pillows and plastic in crib; (14) re- 5. Maintain adequate nutrition, elimination, exercise, social and moving poisonous plants from house and garden; and (15) remov- personal relationships, and so on ing lead-based paint. 6. Use regular oral care and dental examinations Children should be screened at birth for congenital anomalies, 7. Use protection against excessive sun exposure phenylketonuria (PKU), thyroid function, cystic fibrosis, vision 8. Maintain weight within normal range for age, sex, and height impairment, and hearing deficiency. A newborn assessment should 9. Maintain an environment free of chemical, biologic, and phys- be performed, and anticipatory guidance should be provided for ical hazards patients regarding growth and development, safety, health promo- 10. Maintain regular sleep and rest patterns tion, and disease prevention. 11. Practice healthy nutritional intake (e.g., low salt, sugar, and fat Well-baby examinations and developmental assessments are intake with recommended intake from pyramid food groups recommended at 2, 4, 6, 15, and 18 months.10,16 Height and weight and total calories as appropriate for age, sex, and condition) should be recorded on growth charts, with hemoglobin and hema- 12. Maintain regular relaxation, recreation, and exercise activities tocrit checked at least once during infancy. Parent counseling in- Secondary prevention indicates those activities designed to detect cludes discussion of nutrition with attention paid to iron-rich disease before symptoms are recognized. These activities include: foods; safety and accident prevention; oral, perineal, and perirectal hygiene; sensory stimulation of the infant; baby-bottle tooth decay; 1. Glaucoma screening and the effects of passive smoking. Immunizations are given dur- 2. Hypertension screening ing the well-baby checks according to the following schedule17,18: 3. Hearing and vision testing 4. Pap smears 1. Hepatitis B-1 at birth to 2 months 5. Breast examinations 2. Hepatitis B-2 at 1 month to 4 months 6. Prostate and testicle examinations 3. DTaP (diphtheria and tetanus toxoids and acellular pertussis) 7. Well-baby examinations or DTP (diphtheria, tetanus toxoids and pertussis), HiB 8. Colon and rectal examinations (Haemophilus influenzae type B), and polio at 2 and 4 months 4. DTaP and HiB at 6 months Tertiary prevention refers to the treatment, care, and rehabilita- 5. Hepatitis B-3 and polio at 6 to 18 months tion of current illness. This area indicates the patient needs to: 6. HiB at 12 to 18 months18–20 Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 19 7. MMR (measles, mumps, and rubella), varicella, and tuberculin of a single characteristic. Because of the child’s curiosity and ex- test at 12 to 18 months ploration of the environment, it is important for the care provider 8. DTaP or DTP at 15 to 18 months to provide a safe environment. During this period the words “no,” 9. DTaP or DTP, polio, and MMR at 4 to 6 years “hot,” “sharp,” and “hurt” should be repeatedly introduced and re- 10. Hepatitis B, Td (tetanus and diphtheria toxoid), MMR, and inforced by the care provider. Safety rules should be taught and re- varicella at 11 to 12 years21 inforced repeatedly. From ages 4 to 7 years, the child can begin to see simple For children who have not been immunized during the first year of relationships and has the beginning ability to think in logical life, you will need to consult the latest established standards for ap- classes. The child can learn his or her own address and can follow propriate timetables.17,22 Hepatitis B vaccine (HBv) should be given directions of three steps. Rules need to be reinforced. The at birth, 2 to 4 months, and 6 to 18 months.18,23 HBv can be ad- child can be responsible for personal hygiene with instruction and ministered at the same time as DTP and/or Haemophilas influenzae coaching. type B conjugate vaccine (HibCV).23 Strategies used to provide a safe environment for the infant Host factors such as age and behavior affect the susceptibility to should also be used during childhood. Discipline, accident pre- infectious disease. In general, most infectious diseases produce the vention, and the development of self-care proficiency related to greatest morbidity and mortality in the very old and the very eating, dressing, bathing, and dental hygiene are important areas young.24 It is also important to note that the normal newborn has of concern. Developmental assessments with emphasis on hear- a white blood cell count that is higher than that of the normal adult. ing, vision, and speech are recommended. DPT or DTaP and OPV The normal white blood cell count decreases gradually throughout (oral polio vaccine) or IPV (inactivated polio vaccine) are given childhood until reaching the adult norms.25 It is essential that the once between ages 4 and 6, at or before school entry. Consult nurse be very familiar with the blood cell count norms for this age guidelines if the child has not been immunized during the first group. year of life.17,22 The Immunizations Practices Advisory Commit- During fetal life, the fetus is protected by maternal antibodies tee (ACIP) of the U.S. Public Health Service27 recommends that a (assuming the mother has developed antibodies to these diseases) second dose of MMR be given at 4 to 5 years, when the child en- to diseases such as diphtheria, tetanus, measles, and polio. This ters kindergarten. temporary immunity lasts 3 to 6 months. Colostrum contains an- Anticipatory guidance should be given to parents on the devel- tibodies that provide protection against enteric pathogens. Some opment of initiative and guilt, nutrition and exercise, safety and ac- infections can cross the placental barrier, leading to the develop- cident prevention, toothbrushing and dental care, effects of passive ment of congenital (present at birth) infections. Syphilis, HIV, smoking, and skin protection from ultraviolet light.15 Additionally, and rubella are examples of such infections. Pathogenic organ- the parents should be taught that, as the child begins

to explore the isms such as herpes simplex may be acquired during passage environment and put objects and foods into his or her mouth, it through the birth canal. Because infants do not begin to produce will be important to ensure that contact with infectious pathogens immunoglobulins until 2 to 3 months after birth, they are or foreign bodies is controlled. Foreign-object-induced infection susceptible to infections for which they have not gained passive should be considered in childhood infections of the external ear, immunity. nose, and vagina. TORCH infections (toxoplasmosis, hepatitis B, rubella, cy- If the preschooler has been exposed to other children, he or she tomegalovirus, herpes) can be of serious concern during the peri- most likely will have experienced several middle ear, gastrointestinal, natal period.26 When caring for a pregnant female or a newborn, it and upper respiratory tract infections. If the child has not been is important to teach techniques to prevent acquisition and trans- around other children, he or she will likely experience such infec- mission of these disorders and to recognize early signs and symp- tions when entering preschool or kindergarten. Preventing injury toms so that early interventions can be instituted. For newborns, will also assist in the prevention of infection. The adenoidal and ton- the HBv series should be initiated at birth before discharge from the sillar lymphoid tissue may normally enlarge during the early school hospital.23 years, partly in response to the exposure to pathogens in school. Child care practices must include hygienic disposal of soiled di- The child will require assistance with toileting hygiene until 4 to apers and cleaning of the perineum. Proper handwashing tech- 5 years of age. Handwashing techniques can be introduced along nique is required of the care provider. Proper formula preparation with toilet training and followed with consistent role modeling by and storage are also critical if the newborn is to be bottle-fed. the adults and older children with assistance to the child. Bubble Anatomically the eustachian tube of the newborn and infant facili- baths and other scented soaps and toilet tissue may irritate the ure- tates the passage of infection-causing organisms into the middle thra in the female child and lead to urinary tract or vaginal infec- ear. It is important for care providers not to prop bottles, but rather tions. Parents, grandparents, and the child should be taught to to hold the newborn or infant while feeding. Passive exposure to avoid such items. In addition, proper dental hygiene can be taught tobacco smoke irritates the bronchial tree and increases the possi- to the child to help in preventing tooth and gum infections. bility of respiratory infection. The infant may respond to an infection with a very high fever. SCHOOL-AGE CHILD Care providers should be taught how to take axillary temperatures, to provide hydration to an ill infant, to give tepid baths when fever This period is characterized by developing logical approaches to is elevated, and to seek professional evaluation when an infant has concrete problems. The concepts of reversibility and conservation a febrile illness. are developed, and the child can organize objects and events into classes and arrange in order of increasing values. The child can be TODDLER AND PRESCHOOLER responsible for personal hygiene and simple household tasks. The child will need assistance when ill, but he or she can be taught self- During the preoperational period, children learn how to teach care activities as required, such as insulin injections or taking med- themselves through trial and error, exploration, and repetition. ications on a regular basis. The child can distinguish and describe From ages 2 to 4 years, the child is egocentric, using himself or her- physical symptoms and report them to the appropriate caregiver, self as a standard for others; he or she can categorize on the basis and he or she can follow instructions. Copyright © 2002 F.A. Davis Company 20 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Strategies used by care providers to establish a safe environ- proper precautions and use of insecticides, fertilizers, cleaning ment, prevent disease, and promote health can be taught to the products, medications, alcohol, and other toxic substances. child. The child can perform many of these functions with super- vision. Emphasis is placed on health education of the child in ADULT safety and accident prevention, nutrition, substance abuse, and anticipated changes with puberty. Anticipatory guidance for both Adult thought is more refined than adolescent thought because ex- the parents and the child should include the development of in- perience and education allow the adult to differentiate among many dustry and avoidance of inferiority. A preadolescent immuniza- points of view and potential outcomes in an objective and realistic tion status check is recommended at age 11 to 12.18,19 Hepatitis manner. The adult can consider more options and can apply in- B vaccine is recommended for those who did not receive the vac- ductive as well as deductive approaches to problem solving. The cine as a child. Screening of high-risk groups for tuberculosis is adult assumes total responsibility for the care of a child. In middle recommended.10 adult years, the adult may also care for an elderly parent. The adult is concerned about many of the same health promo- ADOLESCENT tion and disease prevention issues the adolescent worries about. Emphasis should be placed on lifestyle counseling related to fam- True logical thought is developed and abstract concepts can be ma- ily planning, parenting, stress management, career advancement, nipulated by the person in this developmental level. A scientific ap- relationship enhancement, hazards at work, and development of proach to problem solving can be planned and implemented. The intimacy and generativity. adolescent can develop, with guidance, responsibility for total self- Regular breast self-examination (women) and testicular self- care. With experience, the adolescent requires less guidance and examination (men) should be taught and encouraged. Women can assume full decision-making responsibility and total responsi- should be advised to have Pap smears regularly. Screening for glau- bility for self-care. coma, high blood pressure, high blood cholesterol level, rubella an- Emphasis should be placed on health education of the adolescent tibodies, sexually transmitted diseases, and colon, endometrial, oral, in healthy living habits, safe driving, sex education, skin care, sub- or breast cancer should be done if the patient is in a risk category. stance abuse, career choices, relationships, dating and marriage, As the body develops more antibodies to pathogens, adults may breast self-examination for female adolescents, and testicular self- find that they do not have as many colds as they used to. Some vi- examination for male adolescents. Screening for pregnancy, sexu- ral infections (e.g., mumps) may present serious consequences to ally transmitted diseases, depression, high blood pressure, and sub- adults (men in the case of mumps). The adult female is as suscep- stance abuse can be done. Anticipatory guidance should be given tible to genitourinary infections as the adolescent. Sexually active to parents and adolescents about the development of identity, role adults are at risk for sexually transmitted diseases. confusion, and formal operational thought.15 Tetanus-diphtheria (Td) boosters should be given every 10 The hormonal changes of puberty may lead to acne vulgaris. If years. Hepatitis B vaccine should be given to people at risk for ex- severe, proper hygiene and dermatologic evaluation will prevent posure. Remember, persons born after 1956 who lack evidence of serious complications. The changes in the vaginal tissue sec- immunity to measles should receive the MMR vaccine, but the ondary to hormonal changes provide an environment conducive MMR vaccine should not be given during pregnancy. Individuals to yeast infections. If the adolescent is engaging in sexual activity, susceptible to mumps should be vaccinated. Pneumococcal and he or she is at risk for exposure to sexually transmitted diseases. influenza vaccines are given based on susceptibility and risk sta- Irritants such as soap and bubble bath may increase the possibil- tus.30 Advanced age, conditions associated with decline in ity of urinary tract infection in female adolescents. Improper gen- antibody levels, Native American ethnicity, institutional settings ital hygiene also predisposes the female adolescent to urinary tract such as military training camps, jails, and boardinghouses all are infection. identified as risk factors30–32 for the development of pneumonia Persons born after 1956 who lack evidence of immunity to and influenza. Tuberculosis screening of high-risk populations is measles should receive the MMR vaccine.18,27 The MMR vaccine recommended.10 should not be given during pregnancy. Individuals susceptible to mumps should be vaccinated.28 A diphtheria and tetanus vaccina- OLDER ADULT tion (Td) should be given at age 14 to 16. Hepatitis B vaccine should be given to anyone who did not receive immunizations as a In the absence of illness affecting cognitive functioning, the older child.19 Screening of high-risk groups for tuberculosis is recom- adult maintains formal operational abilities. The older adult can as- mended.10 Adolescents may be living in group settings, for exam- sume total responsibility for decision making and self-care. The ple, a dormitory, which increases the risk of contracting a commu- older adult also often assumes responsibility for the care of others, nicable disease. Good personal hygiene is important to decrease such as a spouse, child, or grandchild. As with other developmen- this risk. tal levels, illness or physical disability can alter the cognitive func- Risk-taking behavior of adolescents29 may increase the risk of tioning and lead to self-care deficits. infection and accidents. Examples of these risk-taking behaviors Emphasis is on health education related to retirement, safety in include sexual intercourse; IV drug use; use of alcohol and to- the home, medication use, living with chronic illness, and grand- bacco; traumatic injury that breaks the skin, allowing a portal of parenting.33 Anticipatory guidance is related to the development entry for pathogenic organisms; fad diets or other activities that of ego integrity. The importance of regularly scheduled breast decrease the overall health status; improper technique or equip- self-examinations, Pap smears, mammographies (women), and ment in water sports; motor vehicle accidents; running a vehicle testicular self-examinations (men) should be taught and encour- or other combustion engines when not properly ventilated; sub- aged. Glaucoma, blood pressure, cholesterol, and colon cancer stance abuse; choking on food; smoke inhalation; improper stor- screening should also be done.34 Podiatry care should be given as age and handling of guns, ammunition, and knives; smoking in needed. Tetanus-diphtheria (Td) boosters; hepatitis B and A vac- bed; improper use or storage of flammable items, hazardous tools, cines; and influenza, pneumonia, and varicella immunizations are and equipment; drug ingestion; playing or working around toxic given according to the same conditions discussed in the adult vegetation; improper preparation and storage of food; and im- health section.35,36 The inability to achieve adult immunization Copyright © 2002 F.A. Davis Company ENERGY FIELD, DISTURBED 21 recommendations is a serious problem in the United States. It is estimated that only 58 percent of adults age 65 and older receive the influenza vaccine, and only 35 percent receive the pneumo- APPLICABLE NURSING DIAGNOSES coccal vaccine.9 This number is markedly decreased for older His- panic and African-American adults.9 The influenza vaccine Energy Field, Disturbed should be given annually to people 65 and older and to younger people in high-risk groups. The pneumococcal vaccine should be DEFINITION given one time to people 65 or older or to younger people in high- A disruption of the flow of energy surrounding a person’s being that risk groups. If the older adult is at very high risk for pneumococ- results in disharmony of the body, mind, and/or spirit.41 cal infection, the vaccine may be given again 6 years after initial immunization.35 Although the worldwide incidence of tetanus is decreasing, older adults remain more susceptible to the disease. NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; Tuberculosis cases in the United States remain disproportionately CLASS 3—ENERGY BALANCE distributed in the older population and people with acquired im- munity diseases.37 NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; CLASS A—ACTIVITY AND EXERCISE MANAGEMENT Older adults may have a decreased ability to remove themselves from hazardous situations as a result of changes in mobility. Olfac- NOC: DOMAIN I—FUNCTIONAL HEALTH; tory alterations may lead to an inability to smell smoke or gas CLASS A—ENERGY MAINTENANCE fumes.37 The risk for injury and increases in self-care deficits may result from sensory, motor, or perceptual difficulties. DEFINING CHARACTERISTICS41 Age-related changes in the immune system can lead to increased severity and number of infections in

the older adult.37,38 Physical 1. Movement (wave, spike, tingling, dense, flowing) aging changes in the skin, respiratory, gastrointestinal tract, and 2. Sounds (tone, words) genitourinary system can lead to increases in infection. Skin break- 3. Temperature change (warmth, coolness) down due to epidermal thinning and decreased skin elasticity, less 4. Visual changes (image, color) effective coughing, diminished gag reflex, decreased gastrointesti- 5. Disruption of the field (vacant, hold, spike, bulge) nal motility, and urinary stasis can be problematic for the older adult with a less efficient immune system. Changes in the number RELATED FACTORS41 and maturity of T lymphocyte cells lead to decreased ability of the body to destroy infectious organisms. B lymphocyte cells, produc- To be developed. ing immunoglobulins, are less efficient in the presence of fewer and weaker T cells.37 RELATED CLINICAL CONCERNS Older adults with chronic illnesses who are hospitalized or who are in a nursing home are at increased risk for infection. When as- 1. Chronic or catastrophic illness sessing older adults for infection, it is important for the nurse to re- 2. Trauma alize that the signs of infection can be altered with aging. With the 3. Autoimmune deficiency syndrome aging changes of the immune system, and problems with tempera- 4. Insomnia ture regulation, it is not unusual for seriously ill older adults to be 5. Chronic fatigue syndrome afebrile while suffering from an infection. Atypical symptoms lead- 6. Cancer ing the nurse to suspect infection in the older adult include mental 7. Recent surgery status changes, anorexia, functional decline, fatigue, falls, and new 8. Sensory or perceptual disorders or worsened urinary incontinence.37,39,40 9. Pain HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Fatigue For this diagnosis, the client will report field. Interviewing the person regarding sleep exhaustion and lack of energy. Assessment will habits will assist in clarifying whether the primary document an overall reduction of energy, not a diagnosis is Disturbed Sleep Pattern or Disturbed disruption of energy. Energy Field. Activity Intolerance The client will relate, via Disturbed Sensory Perception Determining the interview, specific activities that cannot be person’s orientation to time and place; his or her accomplished. Specific physical findings, such as ability to discern objects in the environment via abnormal pulse and respiration rates, will be vision, touch, sound, or smell; and his or her present during activity. problem-solving abilities will assist in Ineffective Thermoregulation This diagnosis distinguishing Disturbed Energy Field from relates to temperature fluctuations only. Energy Disturbed Sensory Perception. field disruption demonstrates other defining Pain Observing for signs and symptoms of pain characteristics in addition to temperature change. (facial mask, guarding behavior, moaning, or Disturbed Sleep Pattern A problem in the sleep- crying) will distinguish Pain from Disturbed Energy rest pattern could result in alterations in the energy Field. Copyright © 2002 F.A. Davis Company 22 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN EXPECTED OUTCOME TARGET DATES Assessment will demonstrate a consistent energy field by [date]. Locating the reason(s) for Disturbed Energy Field may require sev- eral days or even weeks. Because of complexities involved in ac- cepting this diagnosis for both the client and the nurse, frequent evaluation is required. It is recommended that target dates be no further than 3 days from the date of initial diagnosis. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish trusting relationship with the patient. Promotes accurate assessment. • Allow the patient to talk about condition. Promotes nurse-patient relationship. • Assess energy field. Alterations, variations, and/or asymmetry in the energy field is detected through assessment.42 • Center self: Promotes accurate assessment. � Imagine self as open system with energy flow content in, through, and out of the system. � Consciously quiet your mind; put aside or detach from inward and outward distractions. � Focus full attention and intention on helping patient. • Assess for heat or tingling over specific body areas: � Glide hands, palm down, and slowly move over body, head to toe, 2–4 in above body. • Be sensitive to any images that come to mind: words, symbols, There may be a loss of energy, disruption or blockage in the flow of pictures, colors, sound, mood, emotion, etc.43 energy, or an accumulation of energy in a part of the body.44 • Attempt to get a sense of the dynamics of the energy field. Synthesize assessment data into an understandable format. • Redirect areas of accumulated energy, reestablish the energy Energy transfer or transformation can occur without direct physical flow, and direct energy to depleted areas. Repattern or rebalance contact between two systems.42 Hands are focal points for the patient’s energy field. direction and modulation of energy.42 • Do therapeutic touch for no longer than 10 min. Could disrupt the energy field of the therapist. • Assess the patient’s subjective reaction to therapeutic touch. Nurse acts as a conduit through which the environmental or Patient should feel more relaxed, less anxious, and less pain (if universal energy passes to the patient.42 there were complaints of pain prior to therapeutic touch). • Teach the patient relaxation exercises using some of the same techniques as therapeutic touch: � Assist the patient to center self. Relaxation requires the patient to stop trying and to step outside of � Teach the patient to imagine a peaceful place. Help the patient self and adopt a nontrying attitude. This allows the person to release to visualize place through all the senses and to allow the energy and use the inherent energy of self.45 of the imagined place to bring about a state of calmness. � Teach the patient to scan his or her body to self-assess areas of body or muscle tension. � Assist the patient to consciously relax that tense area of the body. Rebalances energy flow through the body.45 � Practice relaxation at least 10–20 min a day. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for reciprocity of maternal-infant dyad. Provides assessment for causative factors. • Identify developmentally appropriate parameters to determine the Disturbed energy fields may be related to numerous other altered most conducive and therapeutic method for monitoring the patterns due to the infant or child’s basic coping repertoire, child’s energy field.46 especially altered thermoregulation–altered neurologic status. (continued) Copyright © 2002 F.A. Davis Company ENERGY FIELD, DISTURBED 23 (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor energy field with a focus on maintaining self-comforting Will enhance assessment of energy field. activities for the child. May begin with soft music and/or soothing voice.47 • Begin with gentle but firm pressure of hands on one another. Warms hands. • Assess energy field from head to toe. Focus on determining sites Routine assessment. where differences are present. • Attempt to redirect areas of lesser flow or greater flow within an Restores balance. overall free-flowing energy field, allowing 1⁄2–1 in between The infant or child has a small energy field. nurse’s hands and the child. • Monitor the client’s responses to therapeutic touch. Focus on Permits evaluation of success of therapy. identifying stimulus response. • Teach the client (or family, depending on client’s age) to note Promotes early intervention. physical and mental cues that alter energy field, especially stressors.48,49 • Offer age-appropriate relaxation techniques, e.g., imaginary Pays attention to developmental level. floating like a feather to suggest lightness for a school-ager vs. gentle rocking to rhythmic music for an infant.50,51 • Be mindful of contributing factors of self. Offer ways to assist the Provides long-term assistance. caregiver in learning techniques for maintenance of energy field balance. • As appropriate, assist family to develop ways to reduce sensitivity Provides long-term balance. to external triggering cues. Women’s Health Same as Adult Health except for the following: ACTIONS/INTERVENTIONS RATIONALES • Instruct in use of therapeutic touch and stress reduction as a Provides a natural source of dealing with the discomfort of labor.52 means of coping with labor pain. Allows the woman and her newborn to experience a drug-free labor and delivery. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Explain intervention to the client in terms that facilitate reality Prevents reinforcement of delusional system and facilitates the orientation and do not exacerbate thought disorders. development of a trusting relationship.53 � Use examples that elicit the client’s past experience with personal energy fields that do not reinforce delusional beliefs, e.g., EEG and EKG measure electrical energy that flows from the body; walking across the floor and then touching something releases the build-up of energy that can be seen or felt as a mild shock. Rubbing a balloon over the hair and watching it stand up when the balloon is moved away is another example. � Instruct the client that these techniques facilitate his or her own healing potential and are used in conjunction with other treatments. • Discuss with the client his or her perceptions or concerns about Understanding the client’s cognitive map facilitates the development their alterations. of interventions that facilitate client change.53 • Select one of the following methods for altering energy fields All these techniques have been demonstrated to have effects on the based on the assessment: body’s energy fields.44,45,54–59 Application of these interventions by � Therapeutic touch the nurse is related to having appropriate training in the technique. � Foot or hand reflexology If the nurse is unskilled in the techniques, efforts should be made � Visual imagery for appropriate referrals at this point. Additional information on � Visualization with relaxation techniques these techniques can be found in the references. � Acupressure � Transcutaneous electrical nerve stimulation (TENS) � Biofeedback (continued) Copyright © 2002 F.A. Davis Company 24 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Note referral information here with date and time of appointment with practitioner. • Prepare the client and environment for the application of the Increases the client’s level of comfort.53,57 intervention: � Provide private, quiet environment. � Teach the client about the intervention. � Obtain the client’s permission to utilize the intervention. Builds trust and promotes the client’s sense of control.53 � Provide appropriate music that increases the client’s feelings Sound that is loud and irritating can have a negative impact on of comfort. psychological and physiologic well-being.43 � Provide essential oils or other odors that enhance the client’s Odors have impact on the limbic system and impact affect. sense of well-being. • Focus own attention on the intent of the interaction. The nurse’s intention provides a crucial basis for these interventions.44,56 • Inform the client that he or she should tell the practitioner if there Changes that occur with alterations in the energy fields may be are any differences in the way he or she feels during the perceived by the client before the practitioner notices a difference. application of the technique. This could include feelings of The goal of these interventions is to promote balance, so the relaxation, warmth, or change in breathing patterns. treatment should stop when these differences are observed by the client or practitioner.44,45,55 Also promotes the client’s sense of control.45,46 • Assist the client into a comfortable position that will facilitate It is important that the client is well supported because the treatment. techniques do promote the relaxation response. • Utilize selected technique [number] times a day for [number] The ability of the client to maintain balance is based on general levels min. Observe the client for signs that indicate that the desired of wellness, lifestyle, and stressors.55 effect has occurred. This could include: � Sigh � Relaxation in muscles � Slower, deeper breathing � Drop in voice volume � Peripheral flush on the face and neck � Client’s report of feeling different � Reassessment indicates balance has occurred • Assist the client into a comfortable, relaxed position after treatment. • Teach the client those techniques that can maintain balance Maintenance of energy field balance involves a holistic approach to between treatments and that do not require the assistance of care and has been demonstrated to have effects on human energy a practitioner. These include: fields.44,45,54–58 � Relaxation � Cross crawl exercises � Stress reduction � Cognitive reframing � Visualization � Improved nutrition � Decreasing use of tobacco and alcohol • Note teaching schedule and content here. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Obtain medication profile (prescription and over-the-counter) to Medications may contribute to disturbed energy fields. determine whether drug actions or reactions contribute to the disturbance. • Ensure adequate padding and proper position for any sessions. Proper positioning prevents pain, pressure, and thus disturbances

in concentration. • Adjust massage efforts and pressure to compensate for changes in Older adults, with aging changes in the nervous system, may have a older patient’s tactile sensation. decreased perception of being touched. • Use teaching materials, as needed, that are appropriate for the Uncompensated sensory changes of aging can affect the ability to patient (such as printed information of a size that is easily read, use audio-visual sources if the information is not adjusted to meet or quality audiotapes that are not distorted or high pitched). the older adult’s needs. (continued) Copyright © 2002 F.A. Davis Company ENERGY FIELD, DISTURBED 25 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client use of complementary or alternative Older adults may experience psychological or spiritual distress if therapies prior to initiating therapies. therapies used cause a conflict with their belief system. (Some adults may react negatively to therapeutic touch, perceiving it as “laying on of hands” in a religious manner.60) • Teach clients or caregivers relaxation strategies, use of guided The therapies listed are recommended for older adults who would imagery, massage, or music therapies to promote stress reduction. benefit from the reduced sympathetic response to stress. The physical and psychological changes associated with aging can increase stress and impede body/mind healing.61,62 • Ensure that therapeutic touch sessions, if used, are of brief Caution is recommended when using therapeutic touch with infants, duration and gently done. very debilitated patients, and the elderly.63 • Document older adult’s use of any complementary or alternative Many adults are reluctant to discuss use of alternative therapies. therapies, to include preferred treatment, frequency of treatments, Nondisclosure may lead to adverse reactions from drug, food, or and effects experienced. herb interactions.60 • Discuss with clients potential effects from complementary or Little research is currently available on the effects of complementary alternative therapies, such as dizziness or weakness after or alternative therapies on older adults. Cautioning clients on acupuncture, risk for fractures with chiropractic, and drug or potential effects may reduce the risk for injury or adverse herb interactions. reactions.60 Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family to identify disturbances in energy Early identification assists in providing early intervention. field. • Teach the client and family techniques to prevent and/or treat Involvement improves motivation and improves the outcome. disturbed energy field. Self-care is enhanced. � Therapeutic touch � Foot or hand reflexology � Visual imagery � Visualization with relaxation techniques � TENS � Biofeedback • Assist the client and family in providing a private, quiet Client comfort is increased, and response to intervention is environment. enhanced.53,57 • Assist the client and family in identifying resources in the Use of existing community services is efficient use of resources. community, such as: � Massage therapists � Reflexologists � Stress reduction classes Copyright © 2002 F.A. Davis Company 26 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Energy Field, Disturbed FLOWCHART EVALUATION: EXPECTED OUTCOME Does your assessment demonstrate a consistent energy field? Yes No Record data, e.g., record assessment data. Reassess using initial assessment factors. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., assessment shows continued fluctuation Did evaluation show another in energy field. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company HEALTH MAINTENANCE, INEFFECTIVE 27 Health Maintenance, Ineffective 7. Reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas DEFINITION RELATED FACTORS41 Inability to identify, manage, and/or seek out help to maintain health.41 1. Lack of or significant alteration in communication skills (writ- ten, verbal, and/or gestural) NANDA TAXONOMY: DOMAIN 1—HEALTH 2. Lack of ability to make deliberate and thoughtful judgments PROMOTION; CLASS 2—HEALTH MANAGEMENT 3. Perceptual or cognitive impairment (complete or partial lack of BEHAVIORS gross and/or fine motor skills) 4. Ineffective individual coping NIC: DOMAIN 6—HEALTH SYSTEM; CLASS Y— 5. Dysfunctional grieving HEALTH SYSTEM MEDIATION 6. Unachieved developmental tasks 7. Ineffective family coping NOC: DOMAIN IV—HEALTH KNOWLEDGE AND 8. Disabling spiritual distress BEHAVIORS; CLASS Q—HEALTH BEHAVIORS 9. Lack of material resources DEFINING CHARACTERISTICS41 RELATED CLINICAL CONCERNS 1. History of lack of health-seeking behavior 1. Dementias such as Alzheimer’s disease and multi-infarct 2. Reported or observed lack of equipment, financial, and/or other 2. Mental retardation resources 3. Any condition causing an alteration in level of consciousness, for 3. Reported or observed impairment of personal support systems example, closed head injury, carbon monoxide poisoning, or 4. Expressed interest in improving health behaviors cerebrovascular accident 5. Demonstrated lack of knowledge regarding basic health prac- 4. Any condition affecting the person’s mobility level, for example, tices hemiplegia, paraplegia, fractures, or muscular dystrophy 6. Demonstrated lack of adaptive behaviors to internal or external 5. Chronic diseases, for example, rheumatoid arthritis, cancer, environmental changes chronic pain, or multiple sclerosis HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Spiritual Distress A problem in the Value-Belief may assess that Interrupted Family Process exists. Pattern could result in variance in health Rigidity of family functions and roles, poorly maintenance. If the therapeutic regimen causes communicated messages, and failure to conflict with cultural or religious beliefs or with the accomplish expected family developmental tasks individual’s value system, then it is likely some are a few observations to alert the nurse to this alteration in health maintenance will occur. possible diagnosis. Interviewing the patient regarding individual values, Activity Intolerance or Self-Care Deficit The goals, or beliefs that guide personal decision nursing diagnosis of Activity Intolerance or Self- making will assist in clarifying whether the primary Care Deficit should be considered if the nurse diagnosis is Ineffective Health Maintenance or a observes or validates reports of inability to problem in the Value-Belief Pattern. complete the required tasks because of insufficient Ineffective Coping Either Ineffective Individual energy or because of the patient’s inability to feed, Coping or Compromised or Disabled Family bathe, toilet, dress, and groom himself or herself. Coping could be suspected if there are major Powerlessness The nursing diagnosis of differences between the patient and family reports Powerlessness is considered if the patient reports of health status, health perception, and health care or demonstrates having little control over behavior. Ineffective Community Coping may be situations, expresses doubt about ability to present if there are inadequate resources for perform, or is reluctant to express his or her problem solving or deficits in social support feelings to health care providers. services for community members. Verbalizations Deficient Knowledge Deficient Knowledge may by the patient or family member regarding inability exist if the patient or family verbalizes less-than- to cope also indicate ineffective coping. adequate understanding of health management or Community members may express dissatisfaction recalls inaccurate health information. with meeting community needs. Impaired Home Maintenance This diagnosis is Interrupted Family Process Through observing demonstrated by the inability of the patient or family interactions and communication, the nurse family to provide a safe living environment. Copyright © 2002 F.A. Davis Company 28 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN EXPECTED OUTCOME TARGET DATES Will describe at least [number] contributing factors that lead to Assisting patients to adapt their health maintenance requires a sig- health maintenance alteration and at least one measure to alter each nificant investment of time and also requires close collaboration factor by [date]. with home health caregivers. For these reasons, it is recommended the target date be no less than 7 days from the date of admission. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to identify factors contributing to health Healthy living habits reduce risk. Assistance is often required to maintenance alteration through one-to-one interviewing and develop long-term change. Identification of the factors significant value clarification strategies. Factors may include: to the patient will provide the foundation for teaching positive � Stopping smoking50,64–67 health maintenance. � Ceasing drug and alcohol use � Establishing exercise patterns68 � Following good nutritional habits � Using stress management techniques � Using family and community support systems � Using over-the-counter medications � Using herb, vitamins, food supplements, or cleansing programs69 • Develop with the patient a list of assets and deficits as he or she Increases the patient’s sense of control and keeps the idea of perceives them. From this list, assist the patient in deciding what multiple changes from being overwhelming. lifestyle adjustments will be necessary. • Identify, with the patient, possible solutions, modifications, etc., The more the patient is involved with decisions, the higher the to cope with each adjustment. probability that the patient will incorporate the changes. • Develop a plan with the patient that shows both short-term and Avoids overwhelming the patient by indicating that not all goals long-term goals. For each goal, specify the time the goal is to be have to be accomplished at the same time. reached. • Have the patient identify at least two support persons. Arrange Provides additional support for patient in maintaining plan. for these persons to come to the unit and participate in designing the health maintenance plan. • Assist the patient and significant others to develop a list of People most often approach change with “more of the same” potential strategies that would assist in the development of the solutions. If the individual does not think that the strategy will lifestyle changes necessary for health maintenance. (This list have to be implemented, he or she will be more inclined to develop should be a brainstorming process and include those solutions creative strategies for change.69 that appear to be very unrealistic as well as those that appear most realistic). After the list is developed, review each item with the patient, combining and eliminating strategies when appropriate. • Develop with the patient a list of the benefits and disadvantages Placing items in priority according to the patient’s motivation of behavior changes. Discuss each item with the patient as to the increases probability of success. strength of motivation that each item has. • Develop a behavior change contract with the patient, allowing the Positive reinforcement enhances self-esteem and supports patient to identify appropriate rewards and consequences. continuation of desired behaviors. This also promotes patient Remember to establish modest goals and short-term rewards. control, which in turn increases motivation to implement the Note reward schedule here. plan.53 • Teach the patient appropriate information to improve health Provides the patient with the basic knowledge needed to enact the maintenance (e.g., hygiene, diet, medication administration, needed changes. relaxation techniques, and coping strategies). • Review activities of daily living (ADLs) with the patient and Incorporation of usual activities personalizes the plan. support person. Incorporate these activities into the design for a health maintenance plan. (Note: May have to either increase or decrease ADLs.) • Assist the patient and support person to design a monthly Provides a visual reminder. calendar that reflects the daily activities needed to succeed in health maintenance. (continued) Copyright © 2002 F.A. Davis Company HEALTH MAINTENANCE, INEFFECTIVE 29 (continued) ACTIONS/INTERVENTIONS RATIONALES • Have the patient and support person return-demonstrate health Permits practice in a nonthreatening environment where immediate maintenance procedures at least once a day for at least 3 days feedback can be given. before discharge. Times and types of skills should be noted here. • Set a time to reassess with the patient and support person Provides an opportunity to evaluate and to give the patient positive progress toward the established goals. This should be on a feedback and support for achievements. frequent schedule initially and can then gradually decrease as the patient demonstrates mastery. Note evaluation times here. • Provide the patient with appropriate positive feedback on goal achievement. Remember to keep this behaviorally oriented and specific. • Communicate the established plan to the collaborative members Provides continuity and consistency in care. of the health care team. • Refer the patient to appropriate community health agencies for Ensures the service can complete their assessment and initiate follow-up care. Be sure referral is made at least 3–5 days before operations before the patient is discharged from the hospital. Use discharge. of the network of existing community services provides for effective utilization of resources. • Schedule appropriate follow-up appointments for patient before Facilitates patient’s keeping of appointments and

reinforces discharge. Notify transportation service and support persons of importance of health maintenance. these appointments. Write appointment on brightly colored cards for attention. Include date, time, appropriate name (physician, physical therapist, nurse practitioner, etc.), address, telephone number, and name and telephone number of person who will provide transportation. Child Health NOTE: Developmental consideration should always guide the health maintenance planned for the child patient. Also, identification of primary defects is stressed to reduce the likelihood of secondary and tertiary delays. ACTIONS/INTERVENTIONS RATIONALES • Teach the patient and family essential information to establish An individualized plan of care more definitively reflects specific and maintain health according to age, development, and status. health maintenance needs and increases the value of the plan to the patient and his or her family. • Assist the patient and family in designing a calendar to monitor Reinforcement in a more tangible mode facilitates compliance with progress in meeting goals. Offer developmentally appropriate the plan of health maintenance, especially with long-term methods, e.g., toddlers enjoy stickers of favorite cartoon or book situations. characters. • Identify risk factors that will impact health care maintenance, Identification of risk factors allows for more appropriate e.g., prematurity, congenital defects, altered neurosensory anticipatory planning of health care, assists in minimizing crises functioning, errors of metabolism, or altered parenting. and escalation of simple needs, and serves to reduce anxiety. • Begin to prepare for health maintenance on initial meeting with A holistic plan of care realistically includes futuristic goals, not child and family. merely immediate health needs. • Provide appropriate telephone numbers for health team members Anticipatory planning for potential need for communication allows and clinics to the child and parents to assist in follow-up. the patient or family realistic methods for assuming health care while enjoying the back-up of resources. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to describe her perception and understanding Allows assessment of the patient’s basic level of knowledge so that of essential information related to her individual lifestyle and a plan can begin at the patient’s current level of understanding. the adjustment necessary to establish and maintain health in each cycle of reproductive life. ACTIONS/INTERVENTIONS RATIONALES (continued) Copyright © 2002 F.A. Davis Company 30 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) • Develop with the patient a list of stress-related problems at work Provides essential information to assist patient in planning a and at home as she perceives them. From this list, assist the healthy lifestyle. patient in deciding what lifestyle adjustments will be necessary to establish and maintain health. • Identify, with the patient, possible solutions and modification to Provides sequential steps to alternate health maintenance within a facilitate coping with adjustments. Develop a plan that includes defined time period. Keeps the patient from being overwhelmed by short-term and long-term goals. For each goal, specify the time all the changes that might be necessary. the goal is to be reached. • Provide factual information to the patient about menstrual cycle Provides basic information and knowledge that is needed patterns throughout the life span. Include prepubertal, throughout life span. menarcheal, menstrual, premenopausal, menopausal, and postmenopausal phases. • Teach the patient how to record accurate menstrual cycle, Provides the patient with the information necessary to cope with obstetric, and sexual history. Assist the patient in changes throughout the reproductive cycle. recognizing lifestyle changes that occur as a part of normal development. • Discuss pregnancy and the changes that occur during pregnancy Provides patient with the information needed to plan for a healthy and childbearing. Stress the importance of a physical examination pregnancy. before becoming pregnant to include a Pap smear, rubella titer, AIDS profile, and genetic workup (if indicated by family history). • Describe to and assist the patient in planning routines that will Provides the expectant family with information to enable them to maintain well-being for the mother and fetus during pregnancy, make informed choices about pregnancy, childbirth, and beginning e.g., reducing fatigue, eating a nutritionally adequate diet, parenting. exercising properly, obtaining early prenatal care, and attending classes to obtain information about infant nutrition, infant care, and the birthing experience. • Provide information and support during postpartum period to assist the new mother in establishing and maintaining good infant nutrition, whether breastfeeding or formula feeding. • Refer the patient to appropriate groups for support and encouragement after birth of baby, e.g., La Leche League and parenting groups. • Teach terminology and factual information related to spontaneous Allows the patient to grieve and reduces fear regarding subsequent abortion or the interruption of pregnancy. Encourage expression pregnancies. of feelings by the patient and her family. Provide referrals to appropriate support groups within the community. • Provide contraceptive information to the patient, including Allows the patient to plan appropriate contraceptive measures describing different methods of contraception and their according to personal values and beliefs. advantages and disadvantages. • Emphasize the importance of lifestyle changes necessary to cope Provides the patient with basic information that will assist in with postmenopausal changes in the body, such as estrogen planning a healthy lifestyle during and following menopause. replacement therapy, calcium supplements, balanced diet, exercise, and routine sleep patterns. • Teach the patient the importance of routine physical assessment Provides knowledge that allows the patient to plan a healthy throughout the reproductive life cycle, including breast lifestyle. self-examination, Pap smears, and routine examinations by the health care provider of her choice, e.g., nurse midwife, nurse practitioner, or physician. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Include the client in group therapy to provide positive role Group provides opportunities to relate and react to others while models and peer support and to permit assessment of goals exploring behavior with each other. and exposure to differing problem solutions. Copyright © 2002 F.A. Davis Company HEALTH MAINTENANCE, INEFFECTIVE 31 Gerontic Health NOTE: Interventions provided in the adult health section are applicable to older adults. The major emphasis here is on client education. Ageism may present barriers to teaching older clients. The older adult is capable of learning new information.70 Teaching strategies are available to enhance the learn - ing experience for older adults.71 ACTIONS/INTERVENTIONS RATIONALES • Ensure privacy, comfort, and rapport prior to teaching sessions. Reduces anxiety and promotes a nondistracting environment to enhance learning. • Avoid presenting large amounts of information at one time. This encourages increased opportunity to process and store new information. • Monitor energy level as teaching session progresses. • Present small units of information, with repetition, and Compensates for delayed reaction time associated with aging. encourage patient to use cues that enhance ability to recall Promotes retention of information by connecting information to information. previously mastered skills.71 • Use multisensory approach to learning sessions whenever possible. Hearing, vision, touch, and smell used in conjunction can stimulate multiple areas in the cerebral cortex to promote retention.72 Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family to identify home and workplace This action enhances safety and assists in preventing accidents. factors that can be modified to promote health maintenance, Promoting a nonsmoking environment helps reduce the damaging e.g., ramps instead of steps, elimination of throw rugs, use of effects of passive smoke. safety rails in showers, and maintenance of a nonsmoking environment.73,74 • Involve the client and family in planning, implementing, and Involvement improves motivation and the outcome. promoting a health maintenance pattern through: � Helping to establish family conferences � Teaching mutual goal setting � Teaching communication � Assisting family members in specified tasks as appropriate (e.g., cooking, cleaning, transportation, companionship, or support person for exercise program) • Teach the family and caregivers about disease management for Provides a sense of autonomy and prevents premature progression existing illness: of illness. � Symptom management � Medication effects, side effects, and interactions with over-the-counter medications • Teach the client and family health promotion and disease These activities promote a healthy lifestyle. prevention activities: � Relaxation techniques � Nutritional habits to maintain optimal weight and physical strength � Techniques for developing and strengthening support networks (e.g., communication techniques or mutual goal setting) � Physical exercise to increase flexibility, cardiovascular conditioning, and physical strength and endurance75 � Evaluation of occupational conditions73 � Control of harmful habits (e.g., control of substance abuse) � Therapeutic value of pets76 Copyright © 2002 F.A. Davis Company 32 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Health Maintenance, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient describe at least X number of factors leading to own health maintenance alterations? Yes No Can the patient describe at least one No Reassess using initial assessment factors. measure to negate each defined health maintenance etiologic factor? Yes No Is diagnosis validated? Record data, e.g., has enrolled in weight reduction program, has lost 10 lb, etc. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., could only describe one factor or one Did evaluation show another measure. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company HEALTH SEEKING BEHAVIORS (SPECIFY) 33 Health-Seeking Behaviors (Specify) HAVE YOU SELECTED DEFINITION THE CORRECT DIAGNOSIS? A state in which an individual in stable health is actively seeking ways to alter personal health habits and/or the environment in or- Impaired Home Maintenance This diagnosis der to move toward a higher level of health.41* may be involved if the individual or family is unable to independently maintain a safe, growth-promoting immediate NANDA TAXONOMY: DOMAIN 1—HEALTH environment. PROMOTION; CLASS 2—HEALTH MANAGEMENT Powerlessness If the client expresses the NIC: DOMAIN 6—HEALTH SYSTEM; CLASS Y— perception of lack of control or influence HEALTH SYSTEM MEDIATION over the situation and potential outcomes or NOC: DOMAIN IV—HEALTH KNOWLEDGE AND does not participate in care or decision BEHAVIOR; CLASS Q—HEALTH BEHAVIOR making when opportunities are provided, the diagnosis of Powerlessness should be investigated. Community powerlessness may DEFINING CHARACTERISTICS41 be an indicator of Ineffective Community Coping. 1. Expressed or observed desire to seek a higher level of wellness 2. Demonstrated or observed lack of knowledge in health promo- tion behaviors 3. Stated (or observed) unfamiliarity with wellness community re- EXPECTED OUTCOME sources 4. Expression of concern about impact of current environmental Will [increase/decrease] [habit] by [amount] by [date]. conditions on health status 5. Expressed or observed desire for increased control of health EXAMPLES practice Will decrease smoking by 75 percent by [date]. Will increase exercise by walking 2 miles three times per week by RELATED FACTORS41 [date]. To be developed. TARGET DATES RELATED CLINICAL CONCERNS Changing a habit involves a significant investment of time and en- ergy regardless of whether the change involves starting a new habit Because this diagnosis, as indicated by the definition, relates to in- or stopping an old habit. Therefore, the target dates should be ex- dividuals in stable health, there are no related medical diagnoses. pressed in terms of weeks and months. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Initiate discharge plans soon after admission to facilitate Allows adequate time to complete discharge planning and teaching posthospital follow-up. required for home care. • Note potential risk factors that should be dealt with regarding Provides basic knowledge that will contribute to individualized actual health status (e.g., financial status, coping strategies, or discharge planning. resources). • Teach the patient about activities for promotion of health and Provides the patient and family with the essential knowledge prevention of illness (e.g., well-balanced diet, including restricted needed to modify behavior. sodium and cholesterol intake, need for adequate rest and exercise, effects of air pollutants including smoking, and stress management techniques). • Review the patient’s problem-solving abilities, and assist the Promotes shared decision making and enhances patient’s feeling of patient to identify various alternatives, especially in terms of self-control. altering his or her environment. • Provide appropriate teaching to assist the patient and family in Increases sense of self-control and reduces feelings of powerlessness. becoming confident in self-seeking health care behavior, e.g., teach assertiveness techniques to the patient and family. (continued) * Stable health status is defined as age-appropriate illness prevention mea- sures achieved, client reports good or excellent health, and signs and symp- toms of disease, if present, are controlled. Copyright © 2002 F.A. Davis Company 34 HEALTH

PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the patient and family to list benefits of high-level wellness Makes visible the reasons these activities will help the family. and health-seeking behavior. • Help the patient and family develop a basic written plan for Demonstrates importance of follow-up care. achieving individual high-level wellness. Provide time for questions before dismissal to solidify plans for follow-up care. At a minimum, 30 min per day for 2 days prior to discharge should be allowed for this question-and-answer period. Note times here. • Give and review pamphlets about wellness community resources. Reinforces teaching and provides ready reference for patient and family after discharge from agency. • Support the patient in his or her health-seeking behavior. Provides supportive environment and underlines the importance of Advocate when necessary. health-seeking activities. • Refer to appropriate health care providers and various community Provides professional support systems that can assist in groups as appropriate for assistance needed by the patient and health-seeking behavior. his or her family. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the child and family for perceived value of health. Values are formulated in the first 6 years of life and will serve as Incorporate into any plan personal and family needs identified primary factors in how health is perceived and enjoyed by the through this monitoring. individual and family. If values are in question, there is greater likelihood that how health is able to be maintained will be subject to this values conflict. Until health-seeking behavior is identified as a value, follow-up care will not be deemed to be beneficial. • Assist the child and family to identify appropriate health Knowing available resources and incorporating these resources into maintenance needs and resources, e.g., immunizations, nutrition, the plan for health care facilitate long-term attention to health. daily hygiene, basic safety, how to obtain medical services when needed (including health education), how to take temperature of an infant, basic skills and care for health problems, health insurance, Medicaid, and Crippled Children’s Services. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Teach the patient the importance of seeking information and Provides the basic information needed to support health-seeking support during the reproductive life cycle. Include information behaviors. about prepubertal, menarcheal, menstrual, childbearing, parenting, menopausal, and postmenopausal periods of the life cycle. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Assign the client a primary care nurse. Provides increased individuation and continuity of care, facilitating the development of a therapeutic relationship. The nursing process requires that a trusting and functional relationship exist between nurse and client.53 • Primary care nurse will spend 30 min twice a day with client [note times here]. The focus of these interactions will conform to the following schedule: (continued) Copyright © 2002 F.A. Davis Company HEALTH SEEKING BEHAVIORS (SPECIFY) 35 (continued) ACTIONS/INTERVENTIONS RATIONALES � Interaction 1: Have the client identify specific areas of concern. Promotes the client’s perception of control. List the identified concerns on the care plan. Also identify the primary source of this concern (i.e., client, family member, member of the health care team, or other members of the client’s social system). � Interaction 2: List specific goals for each concern the client has Promotes the client’s self-esteem when goals can be accomplished. identified. These goals should be achievable within a 2- to 3-day period. (One way of setting realistic, achievable goals is to divide the goal described by the client by 50 percent.) � Interaction 3: Have the client identify steps that have been Promotes the client’s self-esteem and provides motivation for previously taken to address the concern. continued efforts. � Interaction 4: Determine the client’s perceptions of abilities to meet established goals and areas where assistance may be needed. (If the client indicates a perception of inability to pursue goals without a great deal of assistance, the alternative nursing diagnoses of Powerlessness and Knowledge Deficit may need to be considered.) • All future interactions will be spent assisting the client in developing strategies to achieve the established goals, developing action plans, evaluating the outcome of these plans, and then revising future actions. • Provide positive verbal reinforcement for client’s achievements of goals. This reinforcement should be specific to the client’s goals. Note those things that are rewarding to the client here and the kind of behavior to be rewarded. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Nursing actions for this diagnosis applied to the older adult are essentially the same as those in adult health. • Encourage the client to participate in health-screening and Provides a cost-effective, easily accessible, long-term support health-promotion programs such as Senior Wellness Programs. mechanism for the patient. These programs are often offered by hospitals and senior citizens centers. Home Health ACTIONS/INTERVENTIONS RATIONALES • Help the client identify his or her personal definition of health, Awareness of definition of health, locus of control, perceived perceived personal control, perceived self-efficacy, and efficiency, and health status identifies potential facilitators and perceived health status. barriers to action. • Assist the client in identifying required lifestyle changes. Assist Lifestyle changes require change in behavior. Self-evaluation and the client to develop potential strategies that would assist in the support facilitate these changes. lifestyle changes required. • Assist the client in identifying community resources available to Support systems improve probability of success in implementing assist in necessary lifestyle changes, maintenance of current changes, maintaining health, or improving health. health status, or improvement in current health status. • Refer to Ineffective Health Maintenance for additional actions that would also be applicable with this diagnosis. Copyright © 2002 F.A. Davis Company 36 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Health-Seeking Behaviors (Specify) FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient and significant others. Has the patient (increased/decreased) habit as planned? Yes No Record data, e.g., is walking 3 miles Reassess using initial assessment factors. 3 times a week. Has been achieving this for 2 weeks. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated “need to lose weight, haven’t Did evaluation show another decided how.” Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company INFECTION, RISK FOR 37 Infection, Risk for 7. Malnutrition 8. Immunosuppression DEFINITION 9. Inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response) The state in which an individual is at increased risk for being in- 10. Inadequate acquired immunity vaded by pathogenic organisms.41 11. Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH NANDA TAXONOMY: DOMAIN 11—SAFETY/ secretions, altered peristalsis) PROTECTION; CLASS 1—INFECTION 12. Chronic disease NIC: DOMAIN 4—SAFETY; CLASS V—RISK MANAGEMENT RELATED FACTORS41 NOC: DOMAIN IV—HEALTH KNOWLEDGE AND The risk factors serve also as the related factors. BEHAVIOR; CLASS 5—HEALTH KNOWLEDGE RELATED CLINICAL CONCERNS DEFINING CHARACTERISTICS (RISK FACTORS)41 1. AIDS 2. Burns 1. Invasive procedures 3. Chronic obstructive pulmonary disease (COPD) 2. Insufficient knowledge to avoid exposure to pathogens 4. Diabetes mellitus 3. Trauma 5. Any surgery and any condition where steroids are used as a part 4. Tissue destruction and increased environmental exposure of the treatment regimen 5. Rupture of amniotic membranes 6. Substance abuse or dependence 6. Pharmaceutical agents 7. Premature rupture of membranes HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Self-Care Deficit Self-Care Deficit, especially in the secondary to lack of movement. Skin breakdown areas of toileting, feeding, and bathing-hygiene, may always predisposes the patient to Risk for need to be considered if improper handwashing, Infection. personal hygiene, toileting practice, or food Imbalanced Body Temperature; Hyperthermia preparation and storage have increased the risk of These diagnoses should be considered when the infection. body temperature increases above normal, which Impaired Skin Integrity; Impaired Tissue is common in infectious processes. Integrity; Imbalanced Nutrition, Less Than Body Requirements; Impaired Oral Mucous Membrane Ineffective Management of Therapeutic Regimen These diagnoses may predispose the client to (Noncompliance) This diagnosis may be occurring infection. in cases of inappropriate antibiotic usage or inadequate treatment of wounds or chronic Impaired Physical Mobility This diagnosis diseases. should be considered if skin breakdown is EXPECTED OUTCOME TARGET DATES Will return-demonstrate measures to decrease the risk for infection An appropriate target date would be within 3 days from the date of by [date]. diagnosis. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALE • Monitor vital signs every 4 h around the clock. State times here. Provides a baseline that allows quick recognition of deviations in subsequent measurements. • Use universal precautions and teach the patient and family the Protects the patient and family from infection. purpose and techniques of universal precautions.77–80 (continued) Copyright © 2002 F.A. Davis Company 38 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALE • Maintain adequate nutrition and fluid and electrolyte balance. Helps prevent disability that would predispose infection. Provide a well-balanced diet with increased amounts of vitamin C, sufficient iron, and 2400–2600 mL of fluid daily. • Collaborate with the physician regarding screening specimens Allows accurate determination of the causative organism and for culture and sensitivity, e.g., blood, urine, and spinal fluid. identification of the antibiotic that will be most effective against the organism. • Monitor the administration of antibiotics for maintenance of blood Antibiotics have to be maintained at a consistent blood level, levels and for side effects, e.g., diarrhea. usually 7–10 days, to kill causative organisms. Antibiotics may destroy normal bowel flora, predisposing the patient to the development of diarrhea and increasing the chance of infection in the lower gastrointestinal tract. • Maintain a neutral thermal environment. Avoids overheating or overcooling of room that would contribute to complications for the patient. • Assist the patient with a thorough shower at least once daily Reduces microorganisms on the skin. (dependent on age) or total bed bath daily. • Wash your hands thoroughly between each treatment. Teach the Prevents cross-contamination and nosocomial infections. patient the value of frequent handwashing. • Provide good genital hygiene, and teach the patient how to care Prevents spread of opportunistic infections. for the genital area. • Use reverse or protective isolation as necessary. Protects the patient from exposure to pathogens. • Use sterile technique when changing dressings or performing Protects the patient from exposure to pathogens. invasive procedures. • Turn every 2 h on [odd/even] hour. Prevents inadequate tissue perfusion and stasis of blood. • Cough and deep-breathe every 2 h on [odd/even] hour. Mobilizes static pulmonary secretions. • Perform passive exercises or have the patient perform active range Prevents inadequate tissue perfusion and stasis of blood. of motion (ROM) exercises every 2 h on [odd/even] hour. Remember that the patient may have decreased tolerance of activity. • Teach the patient and family about the infectious process, routes, Provides basic knowledge for self-help and self-protection. pathogens, environmental and host factors, and aspects of prevention. • Consult with appropriate assistive resources as indicated. Appropriate use of existing community service is efficient use of resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor axillary temperature every 2 h on [odd/even] hour. Most appropriate route for frequent measurements for the very young child. Oral temperature measurements would not be accurate. • Encourage the child and parents to verbalize fears, concerns, or Provides support, decreases anxiety and fears, and provides feelings related to infection by scheduling at least 30 min per teaching opportunity. shift to counsel with family. Note times here. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • During prenatal period, inform the mother about and how to Infections acquired during pregnancy can cause significant prevent perinatal infections: morbidity and even mortality for both mother and/or infant. � Encourage the mother to avoid frequent changing of partners and other high-risk sexual behaviors while pregnant. � Teach the mother good preventive health care behaviors such as: Pregnancy is considered an immunosuppressed state. Responses of Maintaining good nutrition the immune system during pregnancy may decrease the mother’s Getting correct amount of sleep ability to fight infection. Exercise Reducing stress levels • Test the mother for presence of TORCH infections. This is a group of organisms that cross the placenta and interfere with the development of the fetus and health of the newborn infant. (continued) Copyright © 2002 F.A. Davis Company INFECTION, RISK FOR 39 (continued) ACTIONS/INTERVENTIONS RATIONALES • In the presence of

ruptured amniotic membranes, monitor for Provides clinical data needed to quickly recognize the presence of signs of infection at least every 4 h at [state times here], e.g., infection. elevated temperature or vaginal discharge odor. • Use aseptic technique when performing vaginal examinations, Reduces the opportunities to introduce infection. and limit the number of vaginal examinations during labor. • Teach the mother to take only showers (no tub baths) and to Teaches the patient basic information to recognize and prevent monitor and record temperature. Have her take temperature at infection. least every 4 h on a set schedule. • Keep linens and underpads clean and changed as necessary Reduces the likelihood of nosocomial infections. during labor. • Monitor incisions (cesarean section or episiotomy) at least every Provides clinical data needed to quickly recognize the presence of 4 h at [state times here] for redness, drainage, oozing, hematoma, infection. or loss of approximation. • During postpartum period, monitor fundal height at least every Provides database necessary to screen for infection. 4 h at (state times here) around the clock for 48 h. • During postpartum period, monitor the patient at least every Provides clinical data needed to quickly recognize the presence of 4 h at [state times here] for any signs of foul smelling lochia, infection. uterine tenderness, or increased temperature. • In instances of abortion, obtain a complete obstetric history. • Monitor abdomen at least every 4 h at [state times here] for any swelling, tenderness, or foul-smelling vaginal discharge following an abortion. • If meconium is present in amniotic fluid, immediately clear Helps prevent aspiration pneumonia in the infant. airway of the infant by suctioning (preferably done by physician immediately on delivery of the infant’s head). • Suction gastric contents immediately. Observe for sternal Indicates development of respiratory complications secondary to retractions, grunting, trembling, jitters, or pallor. If any of these meconium. signs are present, notify the physician at once. • Wash hands each time before and after you handle the baby. Prevents development of nosocomial infections. • Avoid wearing sharp jewelry that could scratch the baby. • Keep umbilical cord clean and dry by cleansing at each diaper change or at least every 2 h on [odd/even] hour. • Monitor circumcision site for swelling, odor, or bleeding each Gives parents basic information regarding prevention of infection diaper change or at least every 2 h on [odd/even] hour. and monitoring for the development of infection. • Demonstrate and have parent return-demonstrate � How to take the baby’s temperature measurement � How to properly care for umbilical cord and circumcision Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the temperature of clients receiving antipsychotic These clients are at risk for developing agranulocytosis. The greatest medications twice a day, and report any elevations to physician. risk is 3–8 wk after therapy has begun. Note times for temperature measurement here. • Monitor the client for the presence of a sore throat in the absence This could be a symptom of agranulocytosis. of a cold or other flu-like symptoms at least daily. Report any occurrence. • Teach the client to report temperature elevations and sore throats in the absence of other symptoms to the physician. • During the first 8 wk of treatment with an antipsychotic, report any signs of infection in the client to the physician for assessment of white cell count. • Review the client’s CBC before antipsychotics are started, and Provides a baseline for comparison after the client has begun report any abnormalities on this and any subsequent CBCs to antipsychotic therapy. the physician. • Teach the client and family handwashing techniques, nutrition, These measures can help prevent or decrease the risk of infection. appropriate antibiotic use, hazards of substance abuse, and universal precautions. Copyright © 2002 F.A. Davis Company 40 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Encourage clients to maintain immunization status, especially Older adults, with aging changes to the immune system, are at annual flu shots, tetanus shot every 10 years, and a one-time increased risk for infection. pneumonia vaccine. • Teach importance of avoiding crowds in the presence of flu or Decreases potential for contact with infectious processes at cold outbreaks. high-risk times. • Teach the client and caregiver atypical signs and symptoms that Older adults may not have fever, localized pain, or other classic may indicate infection in an older adult. signs in the presence of infection. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family measures to prevent transmission of Many infectious diseases can be prevented by appropriate measures. infectious disease to others. Assist the patient and family with The client and family members require this information and the lifestyle changes that may be required: opportunity to practice these skills. � Handwashing � Isolation as appropriate � Proper disposal of infectious waste (e.g., bagging) � Proper use of disinfectants � Appropriate medical intervention (e.g., antibiotics or antipyretics) � Immunization � Signs and symptoms of infection � Treatment for lice and removal of nits � Asepsis for wound care NOTE: Items can be sterilized at home by immersing in boiling water for 10 min. The water needs to be boiling for the entire 10 min. Equipment, such as bedside commodes, bedpans, and other items exposed to blood and body fluids can also be cleaned with a 1:10 bleach and water solution. • Participate in tuberculosis screening and prevention This action serves as the database to identify the need for program.77,81,82 interventions to prevent infections. • Monitor for factors contributing to the risk for infection. • Involve the client and family in planning, implementing, and Family involvement is important to ensure success. promoting reduction in the risk for infection: Communication and mutual goals improve the outcome. � Family conference � Mutual goal setting � Communication • Teach the client and family measures to prevent or decrease These measures reduce the risk of infection. potential for infection: � Handwashing techniques � Universal precautions for blood and body fluids � Personal hygiene and health habits � Nutrition � Immunization schedule � Proper food storage and preparation � Elimination of environmental hazards such as rodents or insects � Proper sewage control and trash collection � Appropriate antibiotic use � Hazards of substance abuse � Preparation and precautions when traveling to areas in which infectious diseases are endemic � Signs and symptoms of infectious diseases for which the client and family are at risk � Preparation for disaster (water storage, canned or dried food, and emergency waste disposal) Copyright © 2002 F.A. Davis Company INFECTION, RISK FOR 41 Infection, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate measures to decrease the risk for infection? Yes No Record data, e.g., can accurately return- Reassess using initial assessment factors. demonstrate handwashing, proper food storage and handling, and use of basic food groups in menu planning. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can accurately return-demonstrate hand- Did evaluation show another washing. States still having problem had arisen? Yes problems with menu planning. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 42 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Injury, Risk for j. Household gas leaks k. Low-strung clothesline DEFINITIONS l. Pacifier hung around infant’s head 2. Internal (individual) Risk for Injury A state in which the individual is at risk of injury a. Reduced olfactory sensation as a result of environmental conditions interacting with the indi- b. Reduced motor abilities vidual’s adaptive and defensive resources.41 c. Cognitive or emotional difficulties Risk for Suffocation Accentuated risk of accidental suffocation d. Disease or injury process (inadequate air available for inhalation).41 e. Lack of safety education f. Lack of safety precautions Risk for Poisoning Accentuated risk of accidental exposure to or C. Risk for Poisoning ingestion of drugs or dangerous products in doses sufficient to 1. External (environmental) cause poisoning.41 a. Unprotected contact with heavy metals or chemicals Risk for Trauma Accentuated risk of accidental tissue injury, for b. Medicines stored in unlocked cabinet accessible to chil- example, wound, burn, fracture.41 dren or confused persons c. Presence of poisonous vegetation d. Presence of atmospheric pollutants NANDA TAXONOMY: DOMAIN 11—SAFETY/ e. Paint, lacquer, and so on in poorly ventilated areas or PROTECTION; CLASS 2—PHYSICAL INJURY without effective protection NIC: DOMAIN 4—SAFETY; CLASS V—RISK f. Flaking, peeling paint or plaster in presence of young MANAGEMENT children g. Chemical contamination of food and water NOC: DOMAIN IV—HEALTH KNOWLEDGE AND h. Availability of illicit drugs potentially contaminated by BEHAVIOR; CLASS T—RISK CONTROL AND SAFETY poisonous additives i. Large supplies of drugs in house DEFINING CHARACTERISTICS (RISK FACTORS)41 j. Dangerous products placed or stored within the reach of children or confused persons A. Risk for Injury 2. Internal (individual) 1. External a. Verbalization of occupational setting without adequate a. Mode of transport or transportation safeguards b. People or provider: Nosocomial agents; staffing patterns; b. Reduced vision cognitive, affective, and psychomotor factors c. Lack of safety or drug education c. Physical: Design, structure, and arrangement of commu- d. Lack of proper precaution nity, building, and/or equipment e. Insufficient finances d. Nutrients: Vitamins, food types f. Cognitive or emotional difficulties e. Biologic: Immunization level of community, microorgan- D. Risk for Trauma ism 1. External (environmental) f. Chemical: Pollutants, poisons, drugs, pharmaceutical a. Slippery floors (e.g., wet or highly waxed) agents, alcohol, caffeine, nicotine, preservatives, cosmet- b. Snow or ice collected on stairs, walkways ics, and dyes c. Unanchored rugs 2. Internal d. Bathtub without handgrip or antislip equipment a. Psychological: Affective, orientation e. Use of unsteady ladders or chairs b. Malnutrition f. Entering unlighted rooms c. Abnormal blood profile: Leukocytosis-leukopenia, al- g. Unsteady or absent stair rails tered clotting factors, thrombocytopenia, sickle cell, tha- h. Unanchored electric wires lassemia, decreased hemoglobin i. Litter or liquid spills on floors or stairways d. Immuno-autoimmune dysfunction j. High beds e. Biochemical, regulatory function: Sensory dysfunction, k. Children playing without a gate at the top of the stairs integrative dysfunction, effector dysfunction, tissue hy- l. Obstructed passageways poxia m. Unsafe window protection in homes with young chil- f. Developmental age: Physiologic, psychosocial dren g. Physical: Broken skin, altered mobility n. Inappropriate call-for-aid mechanisms for bed-resting B. Risk for Suffocation patient 1. External (environmental) o. Pot handles facing toward front of stove a. Vehicle warming in closed garage p. Bathing in very hot water (e.g., unsupervised bathing of b. Use of fuel-burning heater not vented to outside young children). c. Smoking in bed q. Potential igniting gas leaks d. Children playing with plastic bags or inserting small ob- r. Delayed lighting of gas burner or oven jects into their mouth or nose s. Experimenting with chemical or gasoline e. Propped bottle placed in an infant’s crib t. Unscreened fires or heaters f. Pillow placed in an infant’s crib u. Wearing plastic apron or flowing clothes around open g. Eating large mouthfuls of food flame h. Discarded or unused refrigerators or freezers without re- v. Children playing with matches, candles, cigarettes moved doors w. Inadequately stored combustibles or corrosives (e.g., i. Children left unattended in bathtubs or pools matches, oily rags, lye) Copyright © 2002 F.A. Davis Company INJURY, RISK FOR 43 x. Highly flammable children’s toys or clothing yy. Play or work near vehicle pathways (e.g., driveways, y. Overloaded fuse boxes laneways, or railroad tracks) z. Contact with rapidly moving machinery, industrial zz. Nonuse or misuse of seat restraints belts, or pulleys 2. Internal (individual) aa. Sliding on coarse bed linen or struggling within bed a. Lack of safety education restraints b. Insufficient finances to purchase safety equipment or ef- bb. Faulty electrical plugs, frayed wires, or defective fect repairs appliances c. History of previous trauma cc. Contact with acids or alkalis d. Lack of safety precautions dd. Playing with fireworks or gunpowder e. Poor vision ee. Contact with intense cold f. Reduced temperature or tactile sensation ff. Overexposure to sun, sunlamps, or radiotherapy g. Balancing difficulties gg. Use of cracked dinnerware or glasses h. Cognitive or emotional difficulties hh. Knives stored uncovered i. Reduced large or small muscle coordination ii. Guns or ammunition stored unlocked j. Weakness

jj. Large icicles hanging from roof k. Reduced hand-eye coordination kk. Exposure to dangerous machinery ll. Children playing with sharp-edged toys RELATED FACTORS41 mm. High-crime neighborhood and vulnerable clients nn. Driving a mechanically unsafe vehicle The risk factors serve as the related factors for risk diagnoses. oo. Driving after partaking of alcoholic beverages or drugs pp. Driving at excessive speed qq. Driving without necessary visual aid RELATED CLINICAL CONCERNS rr. Children riding in the front seat in car 1. AIDS ss. Smoking in bed or near oxygen 2. Dementias such as Alzheimer’s disease or multi-infarct tt. Overloaded electrical outlet 3. Diseases of the eye such as cataracts or glaucoma uu. Grease waste collected on stoves 4. Medications, for example, hallucinogens, barbiturates, opioids, vv. Use of thin or worn potholders or benzodiazepines ww. Misuse of necessary headgear for motorized cyclists or 5. Epilepsy young children carried on adult bicycles 6. Substance abuse or dependence xx. Unsafe road or road-crossing conditions HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Activity Intolerance This diagnosis should be Impaired Home Maintenance This diagnosis is considered if the nurse observes or validates demonstrated by the inability of the patient or the reports of the patient’s inability to complete family to provide a safe living environment. required tasks because of insufficient energy. Disturbed Thought Process This diagnosis should Insufficient energy could lead to accidents be considered if the patient exhibits impaired through, for example, falling or dropping of items. attention span; impaired ability to recall Impaired Physical Mobility This diagnosis is information; impaired perception, judgment, and appropriate if the patient has difficulty with decision making; or impaired conceptual coordination, range of motion, muscle strength reasoning abilities. This diagnosis could certainly and control, or activity restrictions related to be reflected in increased accidents or injuries. treatment. This could be manifested by the Risk for Violence This diagnosis exists if the frequent occurrence of accidents or injury. accidents or injuries can be related to the risk Deficient Knowledge This diagnosis may exist if factors for self-inflicted or other-directed physical the client or family verbalizes less-than-adequate trauma (e.g., self-destructive behavior, substance understanding of injury prevention. abuse, rage, and hostile verbalizations). EXPECTED OUTCOME TARGET DATES Will identify hazards [list] contributing to risk for injury and at least Although preventing injury may be a lifelong activity, establishing one corrective measure [list] for each hazard by [date]. a mindset to avoid injury can be begun rapidly. An appropriate tar- get date would be within 3 days of admission. Copyright © 2002 F.A. Davis Company 44 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Check on the patient at least once an hour. If risk for injury Primary preventive measures to ensure patient safety. Green dot exists, do not leave patient unattended. Schedule sitters around serves to alert other health care personnel of patient’s status. the clock. If the patient has been identified as being at risk for injury, e.g., falls, place green dot on armband, chart, and head of bed. • Check respiratory rates and depth and chest sounds at least Ongoing monitoring of risk factors. every 4 h at [state times here]. • Do not leave medications, solutions, or any type of liquids in Basic safety measures to prevent poisoning. the room. Use only paper cups and containers that can be disposed of immediately in patient’s room. Use “Mr. Yuk” on bottle labels of poisonous substances. Teach patient and family to use this type of labeling at home. • Keep continuous check on airway patency. Keep suctioning Ongoing monitoring of risk factors. equipment, ventilation equipment, and lavage setup on standby. • Keep bed wheels locked and bed in low position. Keep head of bed elevated at least 30 degrees at all times. • Pad siderails and keep siderails up when patient is in bed. • Make sure handrails are in place in the bathroom and that safety strips are in tub and shower. Do not leave patient unattended in bathtub or shower. • Keep the patient’s room free of clutter. Basic safety measures to prevent injury. • Orient the patient to time, person, place, and environment at Keeps patient aware of environment. least once a shift. • Provide night light. Safety measure to prevent falling at night. • Assist in correcting, to the extent possible, any Correction of sensory-perceptual problems (vision, for example) sensory-perceptual problems through appropriate referrals. will assist in accident prevention. • Assist the patient with all transfer and ambulation. If the patient Assists in preventing suffocation or tripping on pillows. requires multiple pillows for rest or positioning, tape the bottom layer of pillows to prevent dislodging. • Teach the patient and family safety measures for use at home: � Use nonskid rugs or tack down throw rug. � Use handrails. � Install ramps. � Use color contrast for steps, door knobs, electrical outlets, and light switches. � Avoid surface glare (e.g., floors or table tops). Maintain clean, nonskid floors and keep rooms and halls free of clutter. � Change physical position slowly. � Use covers for electrical outlets. � Position pans with handles toward back of stove. � Have family post poison control number for ready reference. � Provide extra lighting in room and night light. • Teach the patient and significant other: Basic safety measures. � Alterations in lifestyle that may be necessary (e.g., stopping smoking, stopping alcohol ingestion, decreasing or ceasing drug ingestion, or ceasing driving) � Use of assistive devices (e.g., walkers, canes, crutches, or wheelchairs) � Heimlich maneuver � Cardiopulmonary resuscitation (CPR) � Recognition of signs and symptoms of choking and carbon monoxide poisoning � Necessity of chewing food thoroughly and cutting food into small bites • Refer to appropriate agency for safety check of home. Make Allows time for checking and correction of problem areas. referral at least 3 days prior to discharge. Copyright © 2002 F.A. Davis Company INJURY, RISK FOR 45 Child Health ACTIONS/INTERVENTIONS RATIONALES • Maintain appropriate supervision of the infant at all times. Allow Will prevent medication or treatment errors. respite time for the parents. Do not leave the infant unattended. Have bulb syringe available in case of need to suction oropharynx. If regular equipment for suctioning is required, validate by checking abel that all safety checks have been completed on equipment. Be aware of potential for young children to answer to any name. Validate identification for procedures in all young children. • Keep siderails of crib up, and monitor safety of all attachments Infants and small children are prone to putting small pieces in for crib or infant’s bassinet. mouth, nose, or ears. Basic safety measures. • Check temperature of water before bathing and formula or food Helps prevent scalding or chilling of the infant. before feeding. Do not microwave formula. • Maintain contact at all times during bathing. Infants unable to sit must be held constantly. Older children should be monitored as well, with special attention given to mental or physical needs for a handicapped child. • Place the infant on back or side or as physician orders. Special Helps prevent aspiration in case of vomiting. New updates instructions may be required with preterm infants and/or those regarding sudden infant death syndrome (SIDS) now provide with special conditions, for example, gastroesophageal reflux. this mandate from the American Academy of Pediatrics. • Investigate any signs and symptoms that warrant potential child Provides assistance for the child and family in instances of child protective service referral. abuse. • Teach family basic safety measures: Ensures environmental safety for the infant or child. � Store plastic bags in cabinet out of child’s reach. � Do not cover mattress or pillows of the infant or child with plastic. � Make certain crib design follows federal regulations and that mattress has appropriate fit with crib frame. � Discourage sleeping in bed with the infant. � Avoid use of homemade pacifiers (use only those of one-piece construction with loop handle). � Do not tie pacifier around the infant’s neck. � Untie bibs, bonnets, or other garments with snug fit around neck of the infant before sleep. � Inspect toys for removable parts and check for safety approval. � Do not feed the infant foods that do not readily dissolve, such as grapes, nuts, and popcorn. � Keep doors of large appliances, especially refrigerators, closed at all times. � Maintain fence and constant supervision around swimming pool. � Exercise caution while cleaning, with attention to pails of water and cleaning solutions. � As the infant or child is able, encourage swimming lessons with supervision and foster water safety. � Use caution in exposure to sun for periods longer than 10 min at a time. � Use appropriate seat belts and car seats according to weight and development. � Keep matches and pointed objects, such as knives, in a safe place out of the child’s reach. � Use lead-free paint on the child’s furniture and environment. � Keep toxic substances locked in cabinet and out of the child’s reach. � Hang plants and avoid placement on floor and tables. � Discard used poisonous substances. � Do not store toxic substances in food or beverage containers. � Administer medication as a drug, not as candy. � Use child-proof medication containers. � Keep syrup of ipecac on hand in case of accidental poisoning. � As applicable, use any special monitoring equipment as recommended for the child. � Monitor mealtimes to prevent aspiration with giggling. Copyright © 2002 F.A. Davis Company 46 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Teach the patient and family the risk for injury to the fetus and Provides initial safety information regarding the well-being of the patient when the pregnant woman smokes, is exposed to fetus. secondhand smoke, or engages in substance abuse, e.g., alcohol and drugs (legal or illegal). • Ask all patients about the existence of violence in their homes. A legal requirement in some states. Report child and elder abuse to proper authorities and any suspicion of family violence. Some states require reporting of violence against women. (See Chapters 9 and 11 for more detailed nursing actions.) • Provide atmosphere that allows the patient considering abortion Allows the patient to receive nonjudgmental information about the to relate her concerns and experiences and to obtain detailed pros and cons of all choices available. information about the method of abortion that is being considered. • Encourage questions and verbalization of the patient’s life expectations. • Provide information on options available to the patient. This is Some states require that information about local women’s shelters especially important in cases of domestic violence. be provided when domestic violence is suspected. • Assist the patient in identifying lifestyle adjustments that the decision could entail. • Involve significant others, if so desired by the patient, in discussion and problem-solving activities regarding lifestyle adjustments. • In instances where the patient has performed a self-induced In self-induced abortion, there is high probability of injury and abortion, obtain detailed information regarding the method subsequent infection. This information provides the health team used. Provide atmosphere that allows the patient to relate her with basic data to begin assessing the degree of injury. experience. • Ascertain whether abortifacients (castor oil, turpentine, lye, ammonia, etc.) were used or whether mechanical means (coat hanger, knitting needles, broken bottle, or knife) were used. • Regardless of the type of abortion, obtain a history from the Provides basic database to initiate planning of care. patient that includes: � Date of last menstrual period � Method of contraception, if any � Previous obstetric history � Known allergies to anesthetics, analgesics, antibiotics, or other drugs � Current drug usage � Past medical history • Note the patient’s mental state, e.g., anxious, frightened, or ambivalent. • Perform physical assessment with special notice of: � Amount and character of vaginal discharge � Temperature elevation � Pain � Bleeding: consistency, amount, and color • Teach the patient the importance of proper storage of birth control pills, spermicides, and medications. • Assist the patient in identifying drugs that are teratogenic to the Provides information that allows the patient to plan for safety fetus. during pregnancy. • Assist the patient in becoming aware of environmental hazards when pregnant, such as x-rays, people with infections, cats (litter boxes), and hazards on the job (surgical gases, industrial hazards). Copyright

© 2002 F.A. Davis Company INJURY, RISK FOR 47 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Orient the client to person, place, and time on each interaction. Disorientation can increase the client’s risk for injury if the environment is perceived as dangerous. • Provide appropriate assistance to the client as he or she moves Prevents falls and possible injury. about the environment. • Monitor level of consciousness every 15 min when the client is Patient safety is of primary importance. Provides information about acutely disoriented following special treatments or when the client’s current status so interventions can be adapted consciousness is affected by drugs or alcohol. If level of appropriately. Prevents aspiration by facilitating drainage of fluids consciousness is impaired, place the client on side to prevent away from airway and prevents falls and possible injury. aspiration of vomitus, and withhold solid food until level of consciousness improves. Place the client in bed with siderails, and keep siderails raised. • Do not allow the client to smoke without supervision when disoriented or when consciousness is clouded. • Provide supervision for clients using new tools that could precipitate injury in special activities such as occupational therapy. • Teach the client and members of support system: � Risks associated with excessive use of drugs and alcohol � Appropriate methods for compensating for sensory-perceptual deficits (e.g., use of pictures or colors to distinguish environmental cues when ability to read is lost) • Remove all environmental hazards (e.g., personal grooming Prevents the client from acting impulsively to injure self with items items that could produce a hazard, cleaning agents, foods that easily found in environment. This allows staff time to offer produce a hazard when taken with certain medicines, plastic alternative coping strategies when clients are experiencing difficulty bags, clothes hangers, belt and ties, or shoestrings). Remove with coping. unnecessary pillows and blankets from the bed. • Maintain close supervision of the client. (If the client is suicidal, Prevents the client from acting impulsively. refer to nursing actions for Risk for Violence, Chapter 9, for specific interventions.) • Check the client’s mouth carefully after oral medicines are given Basic safety precaution. for any amounts that might be held in the mouth to be used at a later date. • If the client is at risk for holding pills in the mouth to be used later, collaborate with physician to have doses changed to liquids or injections. • Keep lavage setup and airway and oxygen equipment on standby. • Talk with the client and members of support system about situations that increase the risk for poisoning, and develop a list of these situations. • Label all medicines and poisonous substances appropriately. Gerontic Health In addition to the following interventions, refer to the applicable interventions provided in the Adult Health and Home Health sections of this diagnosis. ACTIONS/INTERVENTIONS RATIONALES • Refer the independent elder to home health for home safety Provides timely home care planning, and allows implementation of assessment at least 3 days prior to discharge from hospital. safety measures before patient is discharged. • Ensure that any sensory adaptations are made prior to activities. The client may experience increased risks for injury if sensory (Client has clean glasses available as needed, functional hearing losses are not addressed.83 aid if needed, adequate lighting to safely move about, and clear pathway for ambulation.) • Initiate fall precautions, as indicated, on admission to care Use of fall prevention strategies reduces the risk for falls in older facility, or on an as-needed basis. adults and potential loss of function associated with falls and injuries.84,85 (continued) Copyright © 2002 F.A. Davis Company 48 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach at-risk older adults fall prevention strategies: Falls at home or in health care settings are one of the main causes of � Clients using mobility aids morbidity and mortality in older adults.86,87 � Clients on medications that increase the potential for vertigo, weakness, or orthostatic changes � Clients with motor or sensory deficits • Instruct the patient on safe administration of medication. Basic medication safety measures. Monitor for knowledge of drug dosage, reason for medication, expected effect, and possible side effects. Reinforce teaching on a daily basis. • If the patient suffers from dementia, teach the caregiver the Older adults with the diagnosis of dementia often display signs of following safety adaptations88: poor judgment. The listed teaching factors decrease the risk for � Place in a locked closet articles, such as power tools, injury in the home setting. medications, or appliances, that the individual may misuse and injure self or others. � Ensure that water temperature is low enough to prevent scalding. � Remove knobs from stove if cooking is a fire hazard. � Install gates at the top of stairs to prevent falls. � Tape door latches or remove tumblers from locks to prevent the patient from accidentally locking himself or herself in rooms. � Place two locks on entry and exit doors if the individual is prone to wandering. � Ensure that furnishings do not have sharp edges or large areas of glass that could cause injury during a fall. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning, implementing, and Involvement of the client and family enhances motivation and promoting reduction in the risk for injury: increases the possibility of positive outcomes and the long-term � Arrange family conferences. lifestyle changes required. � Assist the family to define mutual goals. � Promote communication. � Assist family members with specific tasks as appropriate to reduce the risk for injury. (Note: Restraining the client may increase, not decrease, the risk for injury.89) It is important to arrange the environment so that the client can avoid injury, e.g., use bedside commode or raised toilet seat; remove unnecessary furniture; pick up objects that may be blocking pathways90–92; remove unsafe or improperly stored chemicals, weapons, cooking utensils, and appliances; use and store safely toxic substances; obtain certification in first aid and CPR; properly store food; obtain knowledge of poisonous plants; learn to swim; remove fire hazards from environment; design and practice an emergency plan for action if fire occurs; and properly use machines powered by petroleum products. • Teach the client and family injury prevention activities as Prevention activities reduce the risk of injury. Many people either appropriate: do not know these prevention strategies or need to have them � Proper lifting techniques reinforced. � Back exercises to prevent back injury � Removal of hazardous environmental conditions, such as improper storage of hazardous substances, improper use of electrical appliances, smoking in bed or near supplemental oxygen, open heaters and flames, and congested walkways � Proper ventilation when using toxic substances � First aid for poisoning � Proper labeling, storage, and disposal of toxic materials such as household cleaning products, lawn and garden chemicals, and medications (continued) Copyright © 2002 F.A. Davis Company INJURY, RISK FOR 49 (continued) ACTIONS/INTERVENTIONS RATIONALES � Proper food preparation and storage � Proper skin, lung, and eye protection when using toxic substances � Toxic substances out of reach of infants and young children � Recognition of toxic plants and removal from environment as indicated � Plan of action if accidental poisoning occurs • Assist the client and family in lifestyle adjustments that may be For long-term change, lifestyle adjustments are often required. required. Many people require assistance with these changes. • Refer to appropriate assistive community resources as indicated. Use of existing community services is efficient use of resources. • Participate in early-return-to-work programs.93 Such programs lead to better client outcomes. • Participate in local, state, and national immunization initiatives.94 Community participation in immunization initiatives improves the rate of appropriate immunization and reduces the risk of outbreak of the diseases for which vaccines are available. Copyright © 2002 F.A. Davis Company 50 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Injury, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient describe/identify potential hazards accurately? Yes No Can the patient identify a corrective measure for No Reassess using initial assessment factors. each identified hazard? Have corrections been made? Yes No Is diagnosis validated? Record data, e.g., has tacked down all throw rugs, safety bars placed in bathroom, strips in tub. Has follow-up appointment at optometrist. Record RESOLVED. Delete nursing diagnosis, expected outcome, target Record new assessment data. date, and nursing actions. If CONTINUE, Record REVISE. Add new change target date and nursing actions. diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., could only describe one factor or one Did evaluation show another measure. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company LATEX ALLERGY RESPONSE, RISK FOR AND ACTUAL 51 Latex Allergy Response, Risk for and Actual 6. Allergies to poinsettia plants 7. History of allergies and asthma DEFINITION B. Latex Allergy Response 1. Type I reactions: Immediate At risk for or demonstrates an allergic reaction to natural latex rub- 2. Type IV reactions ber products.41 a. Eczema b. Irritation NANDA TAXONOMY: DOMAIN 11—SAFETY/ c. Reaction to additives causes discomfort (e.g., thiurams, PROTECTION; CLASS 5—DEFENSIVE PROCESSES carbamates) d. Redness NIC: DOMAIN 4—SAFETY; CLASS V—RISK e. Delayed onset (hours) MANAGEMENT 3. Irritant reactions NOC: DOMAIN II—PHYSIOLOGIC HEALTH; a. Erythema CLASS H—IMMUNE RESPONSE b. Chapped or cracked skin c. Blisters DEFINING CHARACTERISTICS41 RELATED FACTORS41 A. Risk for Latex Allergy Response 1. Multiple surgical procedures, especially from infancy (e.g., No immune mechanism response. spina bifida) 2. Allergies to bananas, avocados, tropical fruits, kiwi, or chest- RELATED CLINICAL CONCERNS nuts 3. Professions with daily exposure to latex (e.g., medicine, 1. Any immune suppressed condition nursing, or dentistry) 2. History of multiple surgeries 4. Conditions needing continuous or intermittent catheteriza- 3. History of multiple allergies tion 4. Asthma 5. History of reaction to latex (e.g., balloons, condoms, or gloves) 5. Urinary bladder dysfunctions HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Tissue Integrity In this instance, the Ineffective Protection The patient with this client has actual tissue damage secondary to diagnosis will have a decrease in the ability to mechanical injury, radiation, etc. There will be guard against internal or external threats. The actual breaks in the tissue, not just erythema or related factors for this diagnosis are much broader blisters. than just one response to an identified allergen. EXPECTED OUTCOME TARGET DATES Will describe at least [number] different measures to use to avoid With appropriate therapy, the signs and symptoms of Latex Allergy Latex Allergy Response by [date]. Response begin to abate within 48 to72 hours; thus, an appropri- ate target date would be 2 to 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Type I reaction: Anaphylactic emergency. � Remove all latex products possible. � Stop treatment or procedure. � Support airway; administer 100 percent oxygen. � Start IV with volume expander. � Administer epinephrine according to physician order. (continued) Copyright © 2002 F.A. Davis Company 52 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Give the following drugs according to physician order: Diphenhydramine Methylprednisolone Ranitidine95 • Clearly identify patients who have a latex allergy with signs both Alert all health care workers that latex precautions must be taken in at the bedside and on the chart and armbands.96–98 case emergency services are ever needed. • Isolate the patient if possible. • Encourage patients to purchase and wear a MedicAlert ID bracelet or necklace.96–98 • Report latex allergy to the Food and Drug Administration’s Establishes accurate data on latex allergies. MedWatch program at 1-800-FDA-1088.96–98 • Identify routinely used supplies that contain latex.96–98 Ensures a latex-safe environment. • Identify latex-safe alternatives for these frequently used supplies.96–98 • Remove all latex-containing materials from the patient’s bedside.96–98 • Replace latex-containing items with latex-safe alternatives.96–98 • Notify other departments as needed: Ensures adequate communication among departments and coordination of care to provide a latex-safe environment. � Pharmacy So that medications can be prepared in a latex-free environment using nonlatex products. � Dietary (avoid bananas, avocados, and chestnuts) So that latex gloves worn by the personnel preparing food can be substituted with a vinyl alternative. � Physical Therapy and Occupational Therapy, if appropriate Ensure that all therapy equipment is latex free. � Surgical Services � Respiratory Therapy � Radiology � Laboratory � Material Management � Environmental Services •

Pad blood pressure cuff before taking blood pressure. • Use nonpowdered latex gloves that have low protein content or Aerosolized latex protein from the latex glove powder is one of the vinyl gloves or nitrile gloves made of synthetic material with biggest contributing factors in triggering a latex reaction. latex-like characteristics. When you must wear powdered latex gloves, never snap them on or off. • Use latex-free equipment and keep carts filled with these If a patient has an emergency event, it should not be compounded products. It is particularly critical that latex-free life-support by having equipment that could worsen the event. equipment is included in the carts. • Do not inject through intravenous tubing injection ports. Use stopcock as needed. Use only latex-safe syringes. • Do not aspirate medications through rubber stopper of multidose vials; remove stopper and aspirate contents directly. • Check the manufacturer’s product label for latex content. Ensures a latex-safe environment. • Prohibit latex balloons from the patient’s room. Mylar balloons are a latex-safe alternative. • Include allergy information in all reports given to other departments. • Document the use of latex-free products during care. Monitor Documentation is vitally important in patient care. for any adverse reactions. • If a reaction does occur, document the presence of the reaction, and the steps that were taken to treat it. Document the patient’s response to treatment. • Notify the physician immediately if the patient does have an allergic reaction to latex. • Assess the patient’s and family’s need for education related to latex allergy and provide that which is needed. • Common sources of latex at home and at work: � Art supplies � Bandages � Balloons � Balls (continued) Copyright © 2002 F.A. Davis Company LATEX ALLERGY RESPONSE, RISK FOR AND ACTUAL 53 (continued) ACTIONS/INTERVENTIONS RATIONALES � Carpet backing � Cleaning gloves � Condoms or diaphragms � Diapers � Douche bulbs � Elastic in clothing � Elastic in hair accessories � Erasers � Eye drop bulbs � Feeding nipples � Food handled with latex gloves � Handles (rubber) on tools, racquets, and bicycles � Hot water bottles � Infant toothbrush massager � Koosh balls � Pacifiers � Paints � Rubber clothing (e.g., raincoats) � Rubber toys � Shoes � Tires � Wheelchair cushions • Document the patient’s and family’s response to the teaching. Child Health ACTIONS/INTERVENTIONS RATIONALES RISK FOR • Assess for signs and symptoms suggestive of latex allergy, Identification of at-risk populations aids in diagnosis of latex allergy. including sneezing, coughing, rash, hives, or wheezing in the presence of balloons, Koosh balls, catheters, or other rubber items.99,100 • Determine the history for the infant or child to note any allergic Knowledge of individual’s status assists in identification of at-risk reactions, including triggering event or substance, actual or actual latex allergy and treatment as reference in event of symptoms, treatment required, and exacerbations. recurrence and for preventive suggestions. • Determine whether the infant or child has undergone allergy Documentation of known status is essential to consider possible testing, has received results, and has undergone a treatment change from potential to actual allergenic status. regimen. • Ask whether the infant or child has been diagnosed with a Identification of risk factors assists in prevention of latex allergy condition that requires contact with catheters or other hospital development for all populations. products, such as gloves or monitoring equipment. • Ask whether the infant or child has ever experienced an allergic Surgery imposes a risk for latex allergy development. reaction during surgery. • List any known foods, drugs, or allergenic substances for the Evidence of absence is essential; presence of history will be needed infant or child. for risk reduction for exacerbation. • Provide appropriate identification alerts for records and identification bands as the child is cared for to signify allergenic Proper identification serves to lessen the likelihood of repeated status to latex.99,100 exposure and precipitation of latex allergic response. • Ask the parents how they would identify an allergic reaction in Individualized assessment provides validation of knowledge and their child. values the importance of each possible manifestation of allergic response. • Find out whether the parents are aware of emergency Assessment for treatment is vital to management of possible allergic equipment and treatment that may be required in the event of response to expedite intervention and minimize delay in event of latex allergenic response. emergency. • As dismissal planning is done, ensure the availability of Anticipatory planning assists in empowerment of parents to act in emergency medical services (EMS), how to summon EMS, event of emergency, thereby ensuring best chance for treatment appropriate use of equipment, and how to maintain a plan in without delay. event of need. (continued) Copyright © 2002 F.A. Davis Company 54 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES ACTUAL • Carry out health interview with focus on components to Determination of a latex allergic client alerts all to need for determine positive history or likelihood of latex allergy. precautionary measures. • Note most recent allergy testing, known allergies, current Documentation of status provides appropriate basis for treatment, and plan for how best to prepare for elective surgery precautionary treatment of client. or treatments within hospital or clinic. • Note history of allergenic responses to latex with attention to Identification of risk indices alerts caregivers to likelihood of ongoing risk indices such as implants or need for special precautions to be implemented. medical equipment such as catheters.99,100 • Identify appropriate treatment for known latex allergies to Anticipatory planning will best provide for possible emergency include need for special airway and oxygen delivery equipment, without delay. medications such as epinephrine, and specialists who will be available to assist in event of acute allergenic response. • Provide identification bracelet and appropriate designation of Anticipatory planning and valuing of risk for acute allergenic latex allergy status for the infant or child per medical record response is best met with dissemination to significant caregivers and ensure its appropriate sharing with all who will provide for provision of greater freedom from risk and prevention of latex care for client (including daycare providers, teachers, or sitters). allergic recurrence. • Assess parental knowledge of current plan of care with a focus Anticipatory planning for the individual places value on the on potential allergenic triggers prior to dismissal and for preventive component. ongoing care. • Assess for stressors related to the infant or child’s latex allergy Valuing feelings and perceptions of the client and family fosters status. open communication and provides cues for related nursing needs. Women’s Health NOTE: The nursing actions for a woman with the nursing diagnosis of Latex Allergy are the same as those for Adult Health. Be aware that infants, born to mothers with latex allergies, could themselves be allergic to latex, and all the precautions taken with the mother should be followed with infants. This includes padding the crib well to keep the infant away from the crib mattress covers, which usually have latex in them. Research studies have shown that glove powder binds to latex proteins and is therefore a major haz- ard and contributor to the amount of latex found in the air in operating rooms and patient rooms where gloves are routinely used. It has been shown that patients and health care workers are exposed on a continuous basis when working in rooms in which there is a high usage of gloves with powder, as bound proteins are aerosolized when gloves are dispensed, put on, used, and/or removed from the hands. Health care personnel and patients in labor and delivery are particularly vulnerable and at risk for latex allergy because of the high use of gloves during vaginal examinations of the patient in labor and during cesarean sections. Likewise, the health care worker needs to be aware of the presence of la- tex in nipples on infant bottles. ACTIONS/INTERVENTIONS RATIONALES • Replace all examination gloves and sterile gloves in obstetric A major reason for the increase in sensitization rates in health care units with vinyl or low-allergen, powder-free latex gloves. workers and patients is the use of products containing high levels of extractable proteins, such as powdered, high-allergen gloves. • When using vinyl gloves during pelvic examinations, in surgery, Because of the high failure rate of vinyl gloves, it is recommended to or when dealing in any situation requiring standard precautions, use low-allergen, powder-free latex gloves during high-risk always double glove. situations involving standard precautions; however, if there is a need for the use of no latex products (such as with the latex-sensitive patient or health care worker), then the health care worker using vinyl gloves should double glove for his or her own protection. • Carefully interview the pregnant client and screen for risk for Because of the frequent use of gloves, catheters, etc. in the care of latex allergy. Question about past pregnancy outcomes, these babies, both the baby and the caretaker may have developed particularly if they have had any infants with neural tube defects a sensitivity to latex. (Approximately 72 percent of patients with (e.g., spina bifida). spina bifida are allergic to latex.) • Pregnant mothers who have been involved with the care of a This mother and her newborn are at risk for a potential reaction to previous child that could have involved exposure to latex latex. products, and/or their newborn infant, should be treated with latex avoidance regardless of their allergy status. (continued) Copyright © 2002 F.A. Davis Company LATEX ALLERGY RESPONSE, RISK FOR AND ACTUAL 55 (continued) ACTIONS/INTERVENTIONS RATIONALES • Carefully monitor the woman and her newborn for symptoms of an allergic reaction, including a systemic reaction. • Teach the mother and her family the essentials of latex precautions: � Review routes of exposure � The use of infant and toddler supplies and toys Psychiatric Health Nursing interventions and rationales for this diagnosis are the same as those for Adult Health. Gerontic Health Use information provided in Adult Health section for this diagnosis. Currently there is not evidence avail- able to suggest specific interventions for this diagnosis based on age of the client. Home Health ACTIONS/INTERVENTIONS RATIONALES • Inquire about sensitivity to latex or other related factors at Allows early identification of potential for allergic reactions. onset of care. • Assist the client in acquiring a MedicAlert bracelet when latex Prevents further exposure to latex products. allergy is present. • Assist the client in securing latex-free supplies for home use. Prevents further exposure to latex products. • Educate the client, family members, and potential caregivers Encourages family participation in client care and reduces potential about latex-containing devices and equipment, as well as the for accidental exposure. signs of acute allergic reactions. • Educate the client, family members, and potential caregivers Prevents further morbidity. how to access emergency medical care should an accidental exposure precipitate an acute reaction. Copyright © 2002 F.A. Davis Company 56 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Latex Allergy Response, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient describe at least [number] of measures to avoid latex allergy response? Yes No Reassess using initial assessment factors. Record data, e.g., states “I now know how to read labels, wear only cotton- lined, non-latex gloves, and examine my skin daily for any erythema.” Record RESOLVED. Delete nursing diagnosis, No Is diagnosis validated? expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated “I just don’t think this will Did evaluation show another happen again.” Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN, EFFECTIVE 57 Management of Therapeutic Regimen, RELATED CLINICAL CONCERNS Effective Any condition requiring long-term management; for example, car- diovascular diseases and diabetes mellitus. DEFINITION A pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is satisfactory for meet- HAVE YOU SELECTED ing specific health goals.41 THE CORRECT DIAGNOSIS? NANDA TAXONOMY: DOMAIN 1—HEALTH There are currently no other diagnoses this PROMOTION; CLASS 2—HEALTH MANAGEMENT diagnosis could be compared with or that are NIC: DOMAIN 6—HEALTH SYSTEM; CLASS Y— close to the concept of this diagnosis. This HEALTH SYSTEM MEDIATION diagnosis

could be classified as a wellness diagnosis; that is, the patient with this diagnosis NOC: DOMAIN IV—HEALTH KNOWLEDGE AND is progressing toward wellness and appropriate BEHAVIOR; CLASS Q—HEALTH BEHAVIOR health maintenance. DEFINING CHARACTERISTICS41 1. Appropriate choices of daily activities for meeting the goals of a EXPECTED OUTCOME treatment or prevention program 2. Illness symptoms are within a normal range of expectation Subsequent assessments document continued progress toward 3. Verbalized desire to manage the treatment of illness and pre- health by [date]. vention of sequelae 4. Verbalized intent to reduce risk factors for progression of illness TARGET DATES and sequelae Effective management of a therapeutic regimen requires a lifelong RELATED FACTORS41 commitment by the client. Therefore, target dates will vary from weeks to years. It would be appropriate to set the first target date To be developed. for 1 month after the patient’s discharge. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Allow time for the patient to discuss his or her feelings about the therapeutic regimen. • Support the patient in choices made to effectively manage Encourages the patient’s sense of control and strengthens support therapeutic regimen. systems. • Review availability and use of resources and support groups. • Answer questions about disease process and therapeutic regimen. Provide teaching for any new components of therapeutic regimen. • Assist the patient to solve problems as they arise. Encourages the patient’s sense of self-control. • Allow and monitor self-care while in the hospital. Promotes independence. • Have the patient return-demonstrate activities associated with Provides feedback for skills; reaffirms motivation. therapeutic regimen, e.g., dressing changes; glucose testing; blood pressure checks; counting calories, fat grams, carbohydrates, and sodium intake; self-administering medications. Supervise performance, critique, and reteach as necessary. • Review self-reported plan of activities with the patient, and Provides visual record of plan that is integrated into patient’s continue to encourage its use and the sharing of the plan with lifestyle. the patient’s employer and physician. • Review accomplishment of goals of therapeutic regimen, and Improves motivation and gives the patient a sense of achievement. praise the patient for even small accomplishments. (continued) Copyright © 2002 F.A. Davis Company 58 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow at least 30 min a day for the patient to verbalize possible Provides an opportunity for patient to verbalize and act out conflicts with therapeutic regimen. Role-play possible scenarios. alternate coping strategies in a nonthreatening environment. • Have the patient make follow-up appointments with appropriate Facilitates continuity and consistency of plan. resources or health care providers prior to discharge. • Continue to coordinate care with other health care providers or Promotes patient advocacy. community resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Utilize appropriate age and developmental communication. Assists in developing a trusting relationship with the client and primary caregiver. • Determine the client’s and primary caregiver’s perception of Provides a starting point for discussing and teaching therapeutic condition. regimen. • Assist the family to determine when and where follow-up care Promotes long-term management. will be utilized.46,47 • Offer verbal and emotional reinforcement for appropriate Provides positive reinforcement. attendance to mutually agreed-to criteria. State criteria here, e.g., maintain immunizations. • Acknowledge need for the caregiver to be relieved (at regular Assists in preventing caregiver role strain. Promotes effective intervals) of total responsibilities of dependent infant or child. management. Encourage the caregiver to express feelings regarding responsibility. Delineate community resources that can augment care.46,47 • Identify subsequent factors that are likely to resurface over time, e.g., developmental concerns. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Utilize Prenatal Risk Indicator Tools to identify women who Provides the patient with the information needed to make informed are high risk for pregnancy and birth. Assess and counsel those choices and necessary lifestyle changes in order to maximize health mothers identified as high risk. Assist the patient to plan for herself and her fetus. changes necessary in her lifestyle to maintain pregnancy and health of mother and fetus until birth.101–103 • Provide the new mother with information about various support groups and health care programs when early postpartum discharge occurs. Provide teaching and support on an ongoing basis from time of conception until end of postpartum period for the new mother, her family, and her baby. Provide new parents with written handouts, help-line telephone numbers, follow-up appointments with advanced practice nurse, pediatrician, and obstetrician following postpartum discharge. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] minutes [number] times a day to Promotes the development of a trusting relationship by discuss: communicating respect for the client.58,59 Provides assessment data � His or her understanding of the current situation that will assist in the development of a plan to support client’s � Strategies that assist the client in this management current behaviors. � Support systems � Stressors � Note important data from these discussions here. (continued) Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN, EFFECTIVE 59 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client signs and symptoms that would indicate Promotes the client’s sense of control.53 that assistance is needed with management • Develop with the client a plan for obtaining the necessary assistance when needed • Provide positive social reinforcement and other behavioral Positive reinforcement encourages adaptive behavior and enhances rewards for demonstration of adaptive management. (Those self-esteem.59 things that the client finds rewarding should be listed here with a schedule for use. The kinds of behaviors that are to be rewarded should also be listed.) • Discuss with the client the impact of stress on physiologic and Anxiety decreases coping abilities and physiologic well-being.59 psychological well-being. Develop with the client a plan for Repeated rehearsal of a behavior internalizes and personalizes it.59 learning relaxation techniques, and have client practice technique for 30 min 2 times a day at [times] while hospitalized. Remain with the client during practice session to provide verbal cues and encouragement as necessary. These techniques can include: � Meditation � Progressive deep muscle relaxation � Visualization techniques that require the client to visualize scenes that enhance the relaxation response � Biofeedback � Prayer � Autogenic training • Develop with the client a plan for integrating relaxation Having a concrete plan increases the probability that the behavior techniques into daily schedule at home. will be implemented in the new environment. • Develop with the client a plan to include play into daily Play provides a sense of joy and rejuvenates inner vitality, activities. Note the plan and specific activities here. enhancing coping abilities.59 • Establish a time to meet with the client and those members of Interactions between members of the support system and the his or her support system identified as most important. Note individual can impact individual health and coping.58 Provides an time here. Utilize this time to discuss: opportunity to assess support system’s perspective to assist in developing interventions and further their acceptance of the intervention.52 � Support system’s understanding of the client’s situation � Support system’s perceptions of their involvement with the management of the illness � Support system’s perceptions of their needs at this time • Develop with the members of the support system a plan to meet Increases support system’s sense of control while enhancing the perceived needs. Note this plan here. self-esteem. Provides opportunities for increasing support system coping by recognizing that the illness has an impact on this system.57,59 • Identify, with the client, community support groups that can be Groups can provide hope, information, and role models for coping utilized when he or she returns home. Note those groups and support.59 identified here with a plan for contacting them before the client leaves the hospital. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor at each subsequent contact for continued ability to Physiologic aging or exacerbation of chronic illness may, over time, effectively manage regimen. diminish continued ability to implement regimen. Home Health NOTE: See Home Health plan for Management of Therapeutic Regimen (Individual), Ineffective. The difference is the nurse has assessed Effective and uses the plan of care in a preventive mode to make possible earlier identification of problems. For the individual who is effectively managing care, the nurse supports the current effective behavior. Copyright © 2002 F.A. Davis Company 60 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Management of Therapeutic Regimen, Effective FLOWCHART EVALUATION: EXPECTED OUTCOME Does assessment document continued progress toward health? Yes No Record data, e.g., is exercising daily by Reassess using initial assessment data. walking 2 miles each morning. Is eating low-fat diet. Cholesterol and triglyceride levels within normal limits. Record CONTINUE. (Note: Because this is a long-term and wellness diagnosis, there is not a problem to be resolved.) No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Change target date. Modify nursing actions as necessary. Did evaluation show another problem had arisen? Yes No Finished Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL, FAMILY, COMMUNITY), INEFFECTIVE 61 Management of Therapeutic Regimen B. Noncompliance 1. Behavior indicative of failure to adhere (by direct observation (Individual, Family, Community), Ineffective or by statements of patient or significant others) 2. Evidence of development of complications NOTE: This diagnosis was proposed at the Tenth NANDA Con- 3. Evidence of exacerbation of symptoms ference with the result that a proposal to delete Noncompliance 4. Failure to keep appointments was expected to be presented at the next conference; however, 5. Failure to progress this has not occurred to date. As discussed in the conceptual sec- 6. Objective tests (physiologic measures or detection of markers) tion of this chapter and in the additional information later in this C. Ineffective Management of Therapeutic Regimen (Family) section, there are many people who object to the diagnosis of 1. Inappropriate family activities for meeting the goals of a Noncompliance. For this reason, we will not provide nursing ac- treatment or prevention program tions for Noncompliance but will provide the definition, defin- 2. Acceleration (expected or unexpected) of illness symptoms ing characteristics, and related factors for this diagnosis until it of a family member is officially deleted. In 1994, the categories of Family and Com- 3. Lack of attention to illness and its sequelae munity were added. 4. Verbalized desire to manage the treatment of illness and pre- vention of the sequelae DEFINITIONS 5. Verbalized difficulty with regulation and/or integration of one or more effects or prevention of complication Ineffective Management of Therapeutic Regimen (Individual) 6. Verbalized that family did not take action to reduce risk fac- A pattern of regulating and integrating into daily living a program tors for progression of illness and sequelae for treatment of illness and the sequelae of illness that is unsatis- D. Ineffective Management of Therapeutic Regimen factory for meeting specific health goals.41 (Community) Noncompliance (Specify) The extent to which a person’s and/or 1. Illness symptoms above the norm expected for the number caregiver’s behavior coincides or fails to coincide with a health- and type of population promoting or therapeutic plan agreed on by the person (and/or 2. Unexpected acceleration of illness(es) family and/or community) and health care professional. In the pres- 3. Number of health care resources is insufficient for the inci- ence of an agreed upon, health-promoting or therapeutic plan, per- dence or prevalence of illness(es) son’s or caregiver’s behavior is fully or partially nonadherent 4. Deficits in people and programs to be accountable for illness and may lead to clinically effective, partially effective, or ineffective care of aggregates outcomes.41 5. Deficits in community activities for secondary and tertiary prevention Ineffective Management of Therapeutic Regimen (Family) A 6. Deficits in advocates for aggregates pattern of regulating and integrating into family processes a pro- 7. Unavailable health care resources for illness care gram for treatment of illness and the sequelae of illness that is un- satisfactory for meeting specific health goals.41 RELATED FACTORS41 Ineffective Management of Therapeutic Regimen (Community) A pattern of regulating and integrating into community processes A. Ineffective Management of Therapeutic Regimen (Individual) programs for treatment of illness and the sequelae of illness that is 1. Perceived barriers unsatisfactory for meeting health-related goals.41 2. Social support deficits 3. Powerlessness NANDA TAXONOMY: DOMAIN 1—HEALTH 4. Perceived susceptibility PROMOTION; CLASS 2—HEALTH MANAGEMENT 5. Perceived benefits 6. Mistrust of regimen and/or health care personnel NIC: DOMAIN 6—HEALTH SYSTEM; CLASS Y—

7. Knowledge deficits HEALTH SYSTEM MEDIATION 8. Family patterns of health care 9. Excessive demands made on individual or family NOC: DOMAIN IV—HEALTH KNOWLEDGE AND 10. Economic difficulties BEHAVIOR; CLASS Q—HEALTH BEHAVIOR 11. Decisional conflicts 12. Complexity of therapeutic regimen DEFINING CHARACTERISTICS41 13. Complexity of health care system 14. Perceived seriousness A. Ineffective Management of Therapeutic Regimen 15. Inadequate number and types of cues to action (Individual) B. Noncompliance 1. Choices of daily living ineffective for meeting the goals of a 1. Health care plan treatment or prevention program a. Duration 2. Verbalized desire to manage the treatment of illness and pre- b. Significant others vention of sequelae c. Cost 3. Verbalized that he or she did not take action to reduce risk d. Intensity factors for progression of illness and sequelae e. Complexity 4. Verbalized difficulty with regulation and/or integration of 2. Individual factors one or more prescribed regimens for treatment of illness and a. Personal and developmental abilities its effects or prevention of complications b. Health beliefs 5. Acceleration (expected or unexpected) of illness symptoms c. Cultural influences 6. Verbalized that he or she did not take action to include treat- d. Spiritual values ment regimens in daily routines e. Individual’s value system Copyright © 2002 F.A. Davis Company 62 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN f. Knowledge and skill relevant to the regimen behavior 3. Decisional conflict g. Motivational forces 4. Economic difficulties 3. Health system 5. Excessive demands made on individual or family a. Satisfaction with care 6. Family conflict b. Credibility of provider D. Ineffective Management of Therapeutic Regimen c. Access and convenience of care (Community) d. Financial flexibility of plan To be developed. e. Client-provider relationship f. Provider reimbursement of teaching and follow-up g. Provider continuity and regular follow-up RELATED CLINICAL CONCERNS h. Individual health coverage 4. Network 1. Any diagnosis new to the patient; that is, patient does not have a. Involvement of members in health plan education or experience in dealing with this disorder. b. Social value regarding plan 2. Any diagnosis of a chronic nature, for example, pain, migraine c. Perceived beliefs of significant others headaches, rheumatoid arthritis, or a terminal diagnosis. C. Ineffective Management of Therapeutic Regimen (Family) 3. Any diagnosis that has required a change in health care 1. Complexity of health care system providers, for example, referred from long-time family physician 2. Complexity of therapeutic regimen to cardiologist. HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Deficient Knowledge This is the most appropriate developmental tasks are a few observations that diagnosis if the patient or family verbalizes less- alert the nurse to this possible diagnosis. than-adequate understanding of health management Activity Intolerance or Self-Care Deficit These or recalls inaccurate health information. diagnoses should be considered if the nurse Ineffective Individual Coping or Compromised or observes or validates reports of inability to Disabled Family Coping These diagnoses are complete the tasks required because of insufficient suspected if there are major differences between energy or because of inability to feed, bathe, toilet, the patient and family reports of health status, dress, and groom self. health perception, and health care behavior. Disturbed Thought Processes The nursing Verbalizations by the patient or family regarding diagnosis of Disturbed Thought Processes should inability to cope also indicate this differential be considered if the patient exhibits impaired nursing diagnosis. attention span; impaired ability to recall Dysfunctional Family Processes Through information; impaired perception, judgment, and observing family interactions and communication, decision making; or impaired conceptual and the nurse may assess that Altered Family Processes reasoning abilities. is a consideration. Poorly communicated Impaired Home Maintenance This diagnosis is messages, rigidity of family functions and roles, demonstrated by the inability of the patient or and failure to accomplish expected family family to provide a safe home living environment. ADDITIONAL INFORMATION Several nursing authors have recognized the interdependent na- ture of illness and healing.105,107–110 This interdependence is espe- Some nursing authors object to the term “Noncompliance.”104–107 cially pronounced in chronic illness. As a patient and his or her Compliance can become the basis for a power-oriented relationship family adapts to a chronic condition, noncompliance with pre- in which one is judged and labeled compliant or noncompliant scribed treatment regimens may actually be constructive and ther- based on the hierarchical position of the professional in relation to apeutic, not detrimental.110 The nurse who learns to listen to the the patient. The diagnosis of Noncompliance is to be used for those patient and plan treatments in collaboration with the patient will patients who wish to comply with the therapeutic recommenda- benefit from the wisdom of people experiencing illness.111,112 tions but are prevented from doing so by the presence of certain fac- tors. The nurse can in such situations strive to lessen or eliminate EXPECTED OUTCOME the factors that preclude the willing patient from complying with recommendations. Will return-demonstrate appropriate technique or procedures [list] The principles of informed consent and autonomy108 are critical for self-care by [date]. to the appropriate use of this diagnosis. A person may freely choose not to follow a treatment plan. The nursing diagnosis Noncompli- TARGET DATES ance does not mean that a patient is not willing to obey, but rather that a patient has attempted a prescribed plan and has found it diffi- The specific target dates for these objectives will be directly related cult to follow through with it. The area of noncompliance must be to the barriers identified, the patient’s entering level of knowledge, specified. A patient may follow many aspects of a treatment program and the comfort the patient feels in expressing satisfaction or dis- very well and find only a small part of the plan difficult to manage. satisfaction. The target date could range from 1 to 5 days following Such a patient is noncompliant only in the area of difficulty. the date of admission. Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL, FAMILY, COMMUNITY), INEFFECTIVE 63 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Help the patient and/or family identify potential areas of conflict, Assesses motivation and decreases risk of ineffective management e.g., values, religious beliefs, cultural mores, or cost. of therapeutic regimen. • Start instructions for self-care within 24 h of admission. Provides time to incorporate changes into lifestyle and to practice as necessary before day of discharge from hospital. • Assist the patient and/or family in identifying factors that Assesses motivation and decreases risk of diagnosis development. actually or potentially may impede the desired therapeutic regimen plan: � Sense of control � Language barriers (provide translators, assign nursing personnel to care for patient who speak the patient’s language) � Cultural concerns (cultural mores, religious beliefs, etc.; design a plan that will allow incorporation of the therapeutic regimen within the cultural norms of the patient) � Financial constraints � Knowledge deficits � Time constraints � Level of knowledge and skill related to treatment plan � Resources available to meet treatment plan objectives � Complexity of treatment plan � Current response to treatment plan � Use of nonprescribed interventions � Entry to health care system • Make a list of these potential areas of conflict and help the patient and family problem solve each area one at a time. • Allow opportunities for the patient and family to vent feelings about therapeutic regimen. Schedule at least 30 min at least once per day for this activity. Note times here. • Teach the patient and significant others knowledge and skills needed to implement the therapeutic regimen (e.g., measuring blood pressure, counting calories, administering medications, or weighing self ). • Have the patient and significant others return-demonstrate or Allows sufficient practice time that provides immediate feedback restate principles at least daily for at least 3 consecutive days on skills, etc. prior to discharge. • Design a chart to assist the patient to visually see the Visualization of actual progress promotes implementation of effectiveness of therapeutic regimen (e.g., weight loss chart, prescribed regimen. days without smoking, blood pressure measurements). Begin the chart in hospital within 1 day of admission. Follow up 1 wk after discharge. • Assist in the development of a schedule that will allow the Demonstrates importance of schedule to patient, employer, and patient to keep appointments and not miss work. Forward plan physician. Coordinated effort encourages adherence to regimen. to employer and physician. • Assist the patient in developing time-management skills to Individualizes schedule and highlights need for relaxation and incorporate time for relaxation and exercise. Have patient exercise. develop a typical 1 wk schedule, then work with patient to adapt schedule as needed. • Contract, in writing, with the patient and/or significant others Demonstrates, in writing, the importance of the plan, and by listing for specifics regarding regimen. Have patient and family definitive follow-up times, enhances the probability of regimen establish mutual goal setting sessions. Assign specific family implementation. Involvement increases motivation and improves members specific tasks. Follow up 1 wk after discharge; the probability of success. recheck 6 wk following discharge. • Design techniques that encourage the patient’s or family’s Prevents multiple changes from overwhelming patient, thus implementation of the regimen, such as setting single, avoiding one major contributor to ineffective management of easy-to-accomplish, short-term goals first and progressing to therapeutic regimen. long-term goals as the short-term goals are met. For example, if (continued) Copyright © 2002 F.A. Davis Company 64 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES the idea of stopping smoking is too overwhelming, help the patient design a personal adaptive program; for example, change to a lower tar and nicotine cigarette, timed smoking (only one cigarette per 30 or 60 min), stabilize, then make further reductions. • Teach the patient and significant others assertive techniques that Long waiting periods in offices, unanswered questions, being can be used to deal with dissatisfaction with caregivers. rushed, etc. increase the likelihood of abandoning the regimen. Assertiveness helps the patient and family overcome the feelings of powerlessness and increases the sense of control. • Allow time for the patient and family to verbalize fears related Increases the patient’s sense of control. Facilitates continuity and to therapeutic regimen (e.g., body image, cost, side effects, pain, consistency of plan. or dependency) by devoting at least 30 min per day to this activity. List times here. • Assist in correction of sensory, motor, and other deficits to the extent possible through referrals to appropriate consultants (e.g., occupational therapist, physical therapist, ophthalmologist, audiologist). • Have the patient and/or family design a home care plan. Assist the patient to modify the plan as necessary. Forward the plan to home health service, social service, physician, etc. • Relate any information regarding dissatisfaction to the appropriate caregiver (e.g., to physician, problems with the time spent in waiting room, cultural needs, privacy needs, costs, need for generic prescriptions). • Make follow-up appointments prior to the patient’s leaving the Demonstrates exactly how to make appointments for patient. hospital. Do it from the patient’s room, and put appropriate information regarding appointment on brightly colored card (i.e., name, address, time, date, and telephone number). • Refer the patient and/or family to appropriate follow-up Allows time for home care assessment and initiation of service. personnel, e.g., nurse practitioner, visiting nurse service, social service, or transportation service. Make referral at least 3 days prior to discharge. • Request follow-up personnel to remind the patient of Shares the responsibility for implementing the regimen, and appointments via card or telephone. demonstrates the importance attached to follow-up care by those providers. • For the last 2–3 days of hospitalization, let the patient perform all of his or her own care. Supervise performance, critique, and reteach as necessary. NOTE: For Ineffective Management of Therapeutic Regimen (Community), see Home Health. Child Health NOTE: Because of the dependency of the infant or child, ineffective management will always include both the individual and the family. ACTIONS/INTERVENTIONS RATIONALES • Assist in developing health values of regimen adherence before Initiates idea of individual health management for child’s health the infant’s birth through emphasis of these aspects in childbirth before birth. Allows sufficient time for parents to incorporate these education classes. ideas. • Allow for the infant or child’s schedule in appointment Facilitates comfort for the child, parents, and health care provider. scheduling (e.g., respect for naps, mealtimes). Involve the Demonstrates individuality and increases likelihood of regimen family in planning care for

the infant or child. implementation. • Provide appropriate criteria for monitoring follow-up of the Anticipatory specific planning and knowledge of condition infant or child’s status, especially in instance of chronic enhances self-management behaviors, thereby valuing self-esteem condition, to also demarcate when to call doctor or case and likelihood of continued appropriate follow-up. manager. • Reward progress in the appropriate manner for age and development. (continued) Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL, FAMILY, COMMUNITY), INEFFECTIVE 65 (continued) ACTIONS/INTERVENTIONS RATIONALES • Depending on needs of the infant or child, may, when services The weakest component of many communities relates to care of the cannot be procured, require a change in location with the goal young, thus making consideration of the child a critical of seeking effective therapeutic regimen services. This may component. depend on state and/or local funding with referral on regional basis. Language or educational needs must also be addressed. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Develop a sensitivity for cultural differences of women’s roles Demonstration of understanding of the patient’s culture and and the impact on their implementation of a therapeutic inclusion of these differences in planning increase the probability regimen.113 of effective management of the therapeutic regimen. • Encourage the family to share views of childbirth with health care personnel through classes and interviews.113 • Discuss with the family their traditions and taboos for mother Increases patient satisfaction and compliance, as well as allowing and baby during transitional period after childbirth. For the childbirth instructor and nursing personnel to plan with the example, in some Far Eastern cultures, the mother does not patient and family appropriate care during childbearing. touch the infant for several days after birth. The grandmother or aunts become the primary caregivers for the infant.113,114 FAMILY • Assess the pregnant woman’s and her family’s perception of the Provides basis for plan of care and allows the family to make tasks of pregnancy complicated by high-risk factors, such as informed choices about care needs during and after pregnancy. premature rupture of membranes, premature labor, maternal or fetal illness, and socioeconomic hardships.101–103 • Encourage the family to share concerns of the changes and Allows caregivers to determine importance of compliance with restrictions on family lifestyle as a result of the high-risk treatment regimen to the family and to refer them to the proper pregnancy. (Example: Restrictions on pregnant woman resources. involving changes in homemaking, childrearing, sexuality, social and recreational activities, disruptions in career, and financial commitments.) Help the family identify community agencies and resources that can assist them to better follow the treatment regimen. COMMUNITY • Inform appropriate agencies when new mothers (parents) Allows for appropriate support and follow-up for the new mother exhibit signs and symptoms of nonattachment to their newborn, and her newborn infant. substance abuse, homelessness, and dysfunctional family dynamics that could result in violence or neglect.101–103 • Refer clients to appropriate community agencies (home visiting Ensures smooth, safe transition for new mother and her family into nurses, public health nurses, child protective agencies, etc.) to parenting roles. Ensures physical and psychological stability for the provide new mothers and their infants transitional care during new mother and her infant. Provides continuity of care from the postpartum period (particularly after early discharge). hospital to the home to the primary caregiver (physician, advanced practice nurse, etc.). Psychiatric Health NOTE: It is important to remember that the mental health client is influenced by a larger social system and that this social system plays a crucial role in the client’s ongoing participation with the health care team. The conceptualization that may be most useful in intervention and assessment of the client who does not follow the recommendations of the health care team in this area may be system persistence. Hoffman115 uses this concept to communicate the idea that the system is signaling that it desires to continue in its present manner of organization. This could present a situation in which the individual client indicates to the health care team that he or she desires change, and yet change is not demonstrated because of the constraints placed on the individual by the larger social system (i.e., the family). This places the responsibility on the nurse to initiate a comprehensive assessment of the client system when the diagnosis of Ineffective Management of Therapeutic Regimen or Noncompliance is considered. Copyright © 2002 F.A. Davis Company 66 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN ACTIONS/INTERVENTIONS RATIONALES • Involve the client system in discussions on the treatment plan. Promotes the client’s perceived control and increases potential for This should include: the client’s involvement in the treatment plan. � Family � Individuals the client identifies as important in making decisions related to health (e.g., cultural healers, social institutions such as probation officers, public welfare workers, officials in the school system, etc.) • Discuss with the family their perception of the current situation. Communicates respect of the family and their experience of the This should include each family member, and each should be situation, which promotes the development of a trusting given an opportunity to present his or her perspective. relationship. Provides information about the family’s strengths, and Questions to ask the family include: provides the nurse with an opportunity to support these strengths � What do you think is the difficulty here? in a manner that will facilitate the development of treatment � Who is most affected by the current situation? program that the family will implement.53 � Who is least affected? � What have you done that has helped the most? � The least? � What happened when you tried to work on the situation? � What has changed in the family since the beginning of the current situation? � What is the best advice you have received about this situation? � What is the worst? For further guidance in this process, refer to Wright and Leahey.59 • Discuss with the identified system those factors that inhibit Recognition of those factors that inhibit change can facilitate the system reorganization: development of a plan that eliminates these problems. � Knowledge and skills related to necessary change � Resources available � Ability to use these resources � Belief system about treatment plan � Cultural values related to the treatment plan • Assess the involvement of other systems such as social services, Larger systems often impose “rules” on families that maintain the school systems, and health care providers in the family situation. larger system by sacrificing the families’ coping abilities or becoming overinvolved to the degree that families feel in a one-down position. The primary “rule” blames the family for problems.59 • Assist the system in making the appropriate adjustments in Affirms and promotes client’s strengths. system organization. • Enhance current patterns that facilitate system reorganization. • Role-model effective communication by: Models for the family effective communication that can enhance � Seeking clarification their problem-solving abilities. � Demonstrating respect for individual, family members, and the family system � Listening to expression of thoughts and feelings � Setting clear limits � Being consistent � Communicating with the individual being addressed in a clear manner � Encouraging sharing of information among appropriate system subgroups • Demonstrate an understanding of the complexity of family Promotes the development of a trusting relationship while problems by: developing a positive orientation.53,59 � Not taking sides in family problem solving � Providing alternative explanations of behavior patterns that recognize the contributions of all persons involved in the situation, including health care providers, if appropriate. • Make small changes in those patterns that inhibit system Promotes the client’s control and provides realistic, achievable goals changes. For example, ask the client to talk with the family in for the client, thus preserving self-esteem when change can be the group room instead of in an open public area on the unit, accomplished. or ask the client who washes his or her hands frequently to use a special soap and towel and then gradually introduce more changes in the patterns. • Advise the client to make changes slowly. It is important not to Increases self-esteem and increases desire to continue those expect too much too soon. behaviors that elicit this response. (continued) Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL, FAMILY, COMMUNITY), INEFFECTIVE 67 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide the appropriate positive verbal feedback to all parts of the system involved in assisting with the changes. It is important not to focus on the demonstration of old patterns of behavior at this time. The smallest change should be recognized. • Develop goals with the family that are based on the data Promotes the family’s sense of control and the development of a obtained in the assessment. These goals should be specific and trusting relationship by communicating respect for the client behavioral in nature. system. Accomplishment of goals provides positive reinforcement, which motivates continued behavior and enhances self-esteem.53,59 • Provide positive reinforcement to families for the strengths Positive reinforcement motivates continued behavior and enhances observed during the assessment and subsequent interviews. self-esteem.59 • Encourage communication between family members by: Assists the family in developing problem-solving skills that will � Having family members discuss alternative solutions and serve in future situations, and promotes healthy family goal setting. functioning.59 � Having each family member indicate how he or she might contribute to resolution of the concerns. � Having family members identify strengths of one another and how these can contribute to the resolution of the situation. • Develop teaching plan to provide the family with information Lack of information about the situation can interfere with problem that will enhance their problem solving. Note the content and solving.59 schedule for this plan here. • Provide opportunities for the expression of a range of affect; this Validates family members’ emotions and helps identify can mean having the family discuss situations that promote appropriateness of their affective responses. Persistent, intense laughing and crying together. Express to the family that their emotions can inhibit problem solving.59 Normalizing decreases emotional experiences are normal. sense of isolation and assists in making connections between family members.59 • Contract with the family for specific behavioral homework Suggesting specific tasks can provide the family with new ways to assignments that will be implemented before the next meeting. interact that can improve problem solving.59 These should be concrete and involve only minor changes in the family’s normal patterns. For example, have them start with calling a resource for the information they may need to do something different. If it is difficult for the family to accomplish these tasks, the family system may be having unusual problems with the change process and should be referred to an advanced practitioner for further care. • If the task is not completed, do not chastise the family. Indicate Promotes positive orientation and recognizes that the development that the nurse misjudged the complexity of the task, and assess of change strategies is an interactive process between the family and what made it difficult for the family to complete the task. the health care system.53,59 Develop a new, less complex task based on this information. If the nurse and family continue to have difficulty developing a plan of cooperation, a referral may need to be made to a nurse with advanced training in family systems work. • Communicate the plan to all members of the health care team. Promotes continuity of care and builds trust. • Refer the family to community resources for continued support. Community resources can provide ongoing support. A specific plan Assist family in making these contacts by developing a specific increases opportunities for success.53,59 plan. Note the specific plan here with the types of support needed. • Develop with the family opportunities for them to have time Provides families with positive experiences with one another and together and in various subgroupings (parents, parents with opportunities to rebuild resources for coping. Also assists them in children, children) that involve activities other than those developing a broader identity of the family. They are more than the directly related to the current problem. This could include problem or illness.53,59 respite activities, family play time, relaxation, and other stress reduction activities. Note this plan here. • Before termination, praise the family’s accomplishments. Give Reinforces family’s strengths and promotes self-esteem. Reminds the family credit for the change. family of the new skills

they have acquired.53,59 NOTE: Refer to Home Health for primary interventions for Ineffective Management of Therapeutic Regimen (Community). The primary agencies that are available to assist with community mental health resources are the Mental Health Association and National Alliance for the Mentally Ill (NAMI). NAMI publishes a journal titled Innovations & Research. Both these associations open their membership to professionals, consumers, families of consumers, and members of the community interested in men- tal health issues. The purpose of these organizations is to provide community resources and support for mental health consumers and their families and advocate for mental health consumers. Copyright © 2002 F.A. Davis Company 68 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Gerontic Health Refer to the Adult Health section for list of potential/actual factors present that may impede use of thera- peutic regimen plan. ACTIONS/INTERVENTIONS RATIONALES • Refer to mental health specialist to rule out depression. Depression in the elderly is frequently underdiagnosed and undertreated. • Refer to community resources. The older patient may have concerns related to availability of support systems, costs of medication, and availability of transportation. Use of already available community resources provides a long-term, cost-effective support system. • Establish communication link with primary caregiver and family. Family members may not be geographically available. • Advise family members of availability of managed care resources Provides care options for family to consider. in the community where older client resides. • Provide follow-up support via home visits and telephone Presents opportunities for continued problem solving and contacts. increasing trust. • Assist caregivers in establishing and meeting their needs. Enables continuation of care while decreasing the potential for burnout. • Review with the client and family the therapeutic regimen. Helps determine possible areas of difficulty for client or caregiver. • Provide written, audiotaped, or videotaped information on Provides quick access to information for the caregiver or client. therapeutic regimen to assist client and caregiver in adhering to regimen. • Incorporate a variety of local, regional, or state social services to Information flow may be impeded because of temporary relocation ensure that needed information about the regimen is available or social isolation. to older patients. • Identify older community leaders, via age-related groups or Peer or cohort influences may assist in identifying and promoting associations, who can identify strengths or weaknesses of the problem solving. community (such as senior citizen center members, church groups, and support groups focused on problems common to older adults). Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client, family, or community to delineate factors Barriers and facilitators to ineffective management can be altered contributing to ineffective therapeutic regimen management to improve outcomes. by helping them to assess: � Level of knowledge and skill related to treatment plan � Resources available to meet treatment plan objectives � Appropriate use of resources to meet treatment plan objectives � Complexity of treatment plan � Current response to treatment plan � Use of nonprescribed interventions � Barriers to adherence to prescribed plan or medication • Involve the client, family, and community in planning, Involvement increases motivation and improves the probability implementing, and promoting the treatment plan of success. through106,112,113: � Assisting with family conferences. � Coordinating mutual goal setting. � Promoting increased communication. � Assigning family members specific tasks as appropriate to assist in maintaining the therapeutic regimen plan (e.g., support person for patient, transportation, or companionship in meeting mutual goals). � Identifying deficits in community resources. � Identifying appropriate community resources. � Utilizing population surveillance to detect changes in illness patterns for the community. (continued) Copyright © 2002 F.A. Davis Company MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL, FAMILY, COMMUNITY), INEFFECTIVE 69 (continued) ACTIONS/INTERVENTIONS RATIONALES • Support the client, family, or community in eliminating barriers Many barriers are institutional and can be eliminated or reduced. to implementing the regimen by: � Providing for privacy. � Referring to community services (e.g., church, home health volunteer, transportation service, or financial assistance). � Alerting other health care providers and social service personnel of the problem that long waiting periods create. � Providing for interpreters and for community-based language classes for English speakers to learn other languages as well as for non-English speakers to learn English. � Identifying community leaders to develop coalitions to address the problems identified. � Serving as social activist to encourage necessary participants to complete their tasks. This may include fund-raising, testifying before governing bodies, or coordinating efforts of several groups and organizations. • Assign one health care provider or social service worker, as Continuity of care provides a means for effective problem solving much as possible, to provide continuity in care provision. and early identification of problems. • Assist health care providers and social service workers to Provides motivation for health care providers to take appropriate understand the destructive nature of noncompliance in action when noncompliance is a problem. chronic illness.116 • Make timely telephone calls to clients to discuss care (e.g., 1 day Follow-up with clients reinforces positive behaviors and may aid in after being seen in clinic for minor acute infection, or weekly or early identification of problems. Follow-up also implies support of monthly on a routine schedule for chronically ill person).116 health care professionals. • Collaborate with other health care professionals and social Complex medication and treatment regimens may be difficult for service workers to reduce the number and variety of some clients to adhere to. medications and treatments for chronically ill clients.117–119 • Reteach the client and family appropriate therapeutic activities Reinforcement of information and continued assistance may be as the need arises. required to improve implementation of the therapeutic regimen.119 • Identify unmet needs of the community. Accurate community needs assessment provides data to set community goals. • Involve community leaders and representative sampling of the Collaboration among community leaders and citizens provides community population in focus groups to identify issues and to support for long-term change. develop action plan to meet the unmet needs. • Identify resources available and those needed to implement Appropriate use of existing resources. Provides direction for action plan. development of needed resources. • Create marketing plan to disseminate information and generate Communication of the plan is necessary to sustain interest and interest in plan. increase participation. • Foster community partnerships to ensure the continuation of Long-term maintenance of the plan will require commitment and the plan. collaboration among many groups. Copyright © 2002 F.A. Davis Company 70 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Management of Therapeutic Regimen (Individual, Family, Community), Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient, family, community return-demonstrate techniques or procedures required for self-care? With what degree of accuracy? Yes No Record data, e.g., can measure and self- Reassess using initial assessment factors. administer insulin with 100% accuracy. Has done so for 4 consecutive days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has difficulty in measuring Did evaluation show another insulin dose. Can self- problem had arisen? Yes administer insulin accurately. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company PERIOPERATIVE-POSITIONING INJURY, RISK FOR 71 Perioperative-Positioning Injury, Risk for 3. Diabetes mellitus 4. Malnutrition DEFINITION 5. Arthritis deformans 6. Dementias, such as Alzheimer’s disease or multi-infarct A state in which the client is at risk for injury as a result of the en- vironmental conditions found in the perioperative setting.41 NANDA TAXONOMY: DOMAIN 11—SAFETY/ HAVE YOU SELECTED PROTECTION; CLASS 2—PHYSICAL INJURY THE CORRECT DIAGNOSIS? NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; Risk for Injury This diagnosis is broader CLASS J—PERIOPERATIVE CARE based than Risk for Perioperative- Positioning Injury. The latter would only be NOC: DOMAIN I—FUNCTIONAL HEALTH; used when surgery is involved. CLASS C—MOBILITY Risk for Peripheral Neurovascular Dysfunction This diagnosis is broader DEFINING CHARACTERISTICS (RISK FACTORS)41 based than Risk for Perioperative- Positioning Injury. A comparison of risk 1. Disorientation factors documents a wider variety of risk 2. Edema factors for peripheral neurovascular 3. Emaciation dysfunction. 4. Immobilization 5. Muscle weakness 6. Obesity 7. Sensory or perceptual disturbances due to anesthesia EXPECTED OUTCOME RELATED FACTORS41 Will remain free from any signs or symptoms of perioperative- positioning injury by [date]. The risk factors also serve as the related factors. TARGET DATES RELATED CLINICAL CONCERNS Because of the emergency nature of this diagnosis, target dates 1. Any condition requiring surgical intervention should be set in terms of hours for the first 2 days postoperatively. 2. Peripheral vascular disease NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES GENERAL PRINCIPLES (GENERALLY APPLIES TO ALL POSITIONS, INCLUDING SUPINE) • Keep siderails up on stretcher. Basic safety measures. • The patient should be in a comfortable position whether awake Prevents softening of the skin and indentations of the skin. or asleep; ensure that operating room (OR) bed is dry and free from wrinkles. • Length of operative procedure should always be considered in Certain complications can arise with extended length of operation, positioning and supporting patient during the operation. e.g., low back pain for patient in supine position, or pressure on heels and/or toes from drapes. • Provide adequate exposure of the operative site. • Maintain good anatomic alignment. Pad bony prominences and Prevents impaired circulation, awkward position, or undue pressure points. pressure. • Ensure good respiration with no restrictions. Avoids respiratory complications and assists in providing good oxygenation. • Nerves should be protected—arms, hands, legs, ankles, and Maintains alignment; relieves pressure. feet; use a footboard. • The elderly, very thin, or obese patients should have special Reduces the risk of complication. consideration; assess nutritional status, level of hydration, vascular disease, etc. (continued) Copyright © 2002 F.A. Davis Company 72 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Check mobility and range of motion prior to positioning. Note Avoids unnecessary strain on already compromised joints, etc. any physical abnormalities and/or injuries and how they may affect the proposed position. • Move the patient only when anesthetist indicates patient can be Avoids startling semiconscious patient and provides basic safety. moved, and have a sufficient number of people available to move the patient safely. • Ensure that no metal is touching the patient. Reduces pressure risk and risk of injury if cautery is used. • The dispersion pad should be on a fatty area, e.g., mid to Basic safety measures. upper thigh, depending on operative site. Recheck dispersion pad if patient has to be repositioned. • Place arms at right angles to the patient. Do not hyperextend Avoids strain on arms. the arms. Secure the arms with a restraint around the wrist. • Place the safety belt above the patient’s knees (depending on Avoids compromising circulation in popliteal area. operative site). • Ensure that all supports are padded. Basic safety measures. SPECIFIC POSITIONS Lithotomy • Raise legs at the same time. Reduces strain on hip joints. • Lower legs, slowly at the same time. • Adjust height of stirrups to fit the patient’s legs. • Be sure that no part of the legs touch metal. Prevents electrical burns. • Cover stirrups with linen or place long leg booties on the Protects nerves and circulation. patient’s legs (up to mid thigh). • Pad popliteal space. • Ensure that the patient’s buttocks are over lower break in table. Nephro or Thoracic Surgery • Move the patient slowly and carefully, as a unit; have sufficient Basic safety measure. assistance. • The patient will be on side over the middle break of the table. • Position lower arm at a 90-degree angle away from body. • Place upper arm parallel to lower arm on a separate and high Facilitates respiration; maintains circulation. armboard or straight above the head. Restrain as needed. Protect nerves and muscles. • Support the patient’s sides with padded kidney rests. Provides support for side and back. • Bend bottom leg 45–90 degrees. Top leg should be straight. Stabilizes the patient. • Place pillow(s) between knees and legs and feet. Protects pressure points. Jacksonian (Modified Knee-Chest) NOTE: Patient will probably be put to sleep on the stretcher and then rolled onto the OR table. • Have sufficient assistance to move the patient. Basic safety measure. • Extend arms on armboards above the head. Facilitates respiration; maintains circulation. • Place pillow under ankles. Protects

pressure points. • Support chest. Stabilizes patient’s position. • Turn head to side; ensure an adequate airway. Allows good expansion of chest and promotes gas exchange. Prone (Upper and Lower Back Surgery) NOTE: Patient will probably be put to sleep on the stretcher and then rolled onto a back frame. This allows the back to be hyperextended and supports the chest for good respiration. Actions are the same as for Jacksonian position except: • Place pillows under upper chest, thighs, legs, ankles, and Avoids pressure and strains. Provides good anatomic alignment. feet. Trendelenburg • Support shoulders with padded shoulder rests. Provides stabilization of the patient’s position. Copyright © 2002 F.A. Davis Company PERIOPERATIVE-POSITIONING INJURY, RISK FOR 73 Child Health NOTE: Any procedure requiring prolonged stabilization in a fixed position places neonates and children at risk for this diagnosis; e.g., ECMO (extracorporeal membranous oxygenation) with cannulation of ma- jor vessels requires fixed positioning for several days to 1 week. ACTIONS/INTERVENTIONS RATIONALES • Monitor skin integrity from head to toes with specific attention Decreases likelihood of impact of shearing forces. to head, ears, elbows, back, and heels, or other body parts in direct contact with surface of mattress or lines from monitoring equipment.46 Women’s Health Same as for Adult Health except for the following: ACTIONS/INTERVENTIONS RATIONALES • Determine proper alignment and positioning of mother during Enhances circulation and oxygen supply to the placenta and the the cesarean section and any other procedure in which mother fetus. must lie on back. Place a wedge cushion under the left buttock when positioning mother on surgical table. • Assist the mother’s chosen partner (support person) to prepare Reassures and supports the partner (support person) during for the cesarean section by describing the events that will take surgery, allowing him to be supportive to the pregnant woman. place, explaining his role and where he will sit (a stool or chair next to the mother’s head) during the surgery, and identifying who will assist him. Psychiatric Health Nursing interventions and rationales for this diagnosis are the same as for Adult Health. Mental health clients who are most commonly at risk for this diagnosis are those receiving electroconvulsive therapy (ECT) treatments. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor closely for signs of hypothermia, especially in frail Frail elders are at high risk for hypothermia as a result of changes elders. associated with aging. Elimination of an anesthetic agent may be reduced because of hypothermia. Older adults may have increased oxygen demand secondary to shivering if hypothermia is not treated.120–122 • Provide head and neck support that prevents head rotation or Hyperextension or rotation may cause vertebral circulatory hyperextension. compromise in older patients. • Ensure adequate padding over pressure-prone areas. Decreases potential for circulatory compromise as well as nervous system or skin injury in older patients at risk for these problems. • Observe, especially intraoperatively, for external pressure Compromised circulation or increased skin pressure can result in caused by leaning on patient. patient injury. • Position extremities with caution. Older patients have an increased risk for osteoporosis and, consequently, fractures. Home Health ACTIONS/INTERVENTIONS RATIONALES • Begin preoperative teaching to the client and family as soon as Involvement of the client and family increases motivation. Correct possible postoperatively. Include the need for early ambulation, knowledge supports the behavior and assists in preventing deep-breathing exercises, and adequate pain control. complications. • Involve the home caregiver in developing plan of care to Involvement in the planning increases motivation and success of decrease risk of complications. the intervention. Copyright © 2002 F.A. Davis Company 74 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Perioperative-Positioning Injury, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient exhibit any signs or symptoms of perioperative-positioning injury? No Yes Reassess using initial assessment factors. Record data, e.g., no numbness or tingling; circulation good in both legs; full range of motion. Record RESOLVED. Delete nursing diagnosis, expected No Is diagnosis validated? outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., complains of tingling in left leg; ROM Did evaluation show another limited in left leg. Record problem had arisen? Yes CONTINUE. Change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company PROTECTION, INEFFECTIVE 75 Protection, Ineffective 4. Drug therapies (antineoplastic, corticosteroid, immune, antico- agulant, thrombolytic) DEFINITION 5. Alcohol abuse 6. Treatments (surgery, radiation) The state in which an individual experiences a decrease in the abil- 7. Disease such as cancer and immune disorders ity to guard the self from internal or external threats such as illness or injury.41 RELATED CLINICAL CONCERNS NANDA TAXONOMY: DOMAIN 11—SAFETY/ 1. AIDS PROTECTION; CLASS 2—PHYSICAL INJURY 2. Diabetes mellitus 3. Anorexia nervosa NIC: DOMAIN 4—SAFETY; CLASS V—RISK 4. Cancer MANAGEMENT 5. Clotting disorders, e.g., disseminated intravascular coagulation, NOC: DOMAIN IV—HEALTH KNOWLEDGE AND thrombophlebitis, anticoagulant medications BEHAVIOR; CLASS S—HEALTH KNOWLEDGE 6. Substance abuse or dependence 7. Any disorder requiring use of steroids DEFINING CHARACTERISTICS41 1. Maladaptive stress response HAVE YOU SELECTED 2. Neurosensory alterations THE CORRECT DIAGNOSIS? 3. Impaired healing 4. Deficient immunity Risk for Infection This diagnosis would most 5. Altered clotting likely be a companion diagnosis. Risk means 6. Dyspnea the individual is not presenting the actual 7. Insomnia defining characteristics of the diagnosis, but 8. Weakness there are indications the diagnosis could 9. Restlessness develop. Ineffective Protection is an actual 10. Pressure sore diagnosis. 11. Perspiring 12. Itching 13. Immobility 14. Chilling EXPECTED OUTCOME 15. Cough 16. Fatigue Will return-demonstrate measures to increase self protection by 17. Anorexia [date]. 18. Disorientation TARGET DATES RELATED FACTORS41 Ineffective Protection is a long-lasting diagnosis. Therefore, a date 1. Abnormal blood profiles (leukopenia, thrombocytopenia, ane- to totally meet the expected outcome could be weeks and months. mia, coagulation) However, since the target date signals the time to check progress, 2. Inadequate nutrition a date 3 days from the date of the original diagnosis would be 3. Extremes of age appropriate. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Place the patient in protective isolation, but do not promote an Lessens sense of isolation and maintains therapeutic relationship. isolated feeling for the patient. Encourage frequent telephone calls and visits from significant others. • Check the patient at least every 30 min while awake. Spend 30 min with client every 2 h on [odd/even] hour while awake to answer questions and provide emotional support while in reverse isolation. Note times for these interactions here. • Collaborate with occupational therapist regarding diversionary activity. (continued) Copyright © 2002 F.A. Davis Company 76 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Protect the patient from injury and infection. (See appropriate Protects the patient from infection or spread of infection. nursing actions and rationales under the diagnoses Risk for Injury and Risk for Infection.) • Use universal precautions in caring for the patient. • Monitor: Allows comparison to baseline at admission and evaluation of � Vital signs, mucous membranes, skin integrity, and response effectiveness of therapy. to medications at least once per shift. � Unexplained blood in the urine. � Prolonged bleeding after blood has been drawn or from injection sites. � Side effects of blood and blood products: Monitor for possibility of blood reaction. Take vital signs every 15 min  4, then every 30 min until transfusion completed. In the event of transfusion reaction, stop the transfusion immediately, maintain IV line with saline, and notify physician while monitoring patient for further anaphylactic signs and symptoms. � Effects and side effects of steroids: Improved general status, decreased inflammatory signs and symptoms versus untoward effects including bleeding, sodium (Na) or potassium (K) imbalance. Calculate and record intake and output at least once per shift. � Effects and side effects of antineoplastics, such as nausea, cardiac arrhythmias, extrapyramidal signs and symptoms. These side effects vary according to the specific agents used. Take vital signs every 5–10 min during actual administration and use a cardiac monitor. � Signs and symptoms of infection such as lymphoid interstitial pneumonia or recurrent oral candidiasis. • Apply pressure after each injection and after removal of IV needle. Assists in stopping of bleeding. • Provide oral hygiene or assist the patient with oral hygiene at Prevents opportunistic infection. least 3 times per day. • Provide body hygiene or assist the patient with body hygiene at least once daily at time of the patient’s choosing. • Measure and record intake and output at end of each shift. Monitors effectiveness of bowel and bladder function. • Encourage the patient to eat nutritious meals. Collaborate with Ensures balanced intake of necessary vitamins, minerals, etc., to diet therapist regarding the patient’s likes, dislikes, and assist in tissue repair. Assists in lessening impact of infections. planning for dietary needs after hospital discharge. • Collaborate with physician regarding repeat laboratory Gives guidelines for future therapeutic regimen as well as assessing examinations (CBC, blood coagulation studies, urinalyses, effectiveness of current regimen. drug levels, etc.). • Collaborate with psychiatric nurse practitioner as necessary. Provides source for assistance with interventions for maladaptive stress response. • Teach the patient and significant others: Provides basic knowledge needed for the patient and family to � Medication administration make modifications necessitated by alteration in protective � Signs and symptoms to be reported mechanisms. � Special laboratory or other procedures to be done at home � Anticipatory safety needs � Routine daily care � Appropriate clean and sterile technique � Isolation or reverse-isolation technique � Common antigens and/or allergens and seasonal variations � How to avoid or reduce exposure to antigens and/or allergens (alteration of environment) � Type and use of protective equipment � Universal precautions � Rationale for compliance with prescribed regimen � Resources available for assistance with health care, legal questions, or ethical questions • Collaborate with other health professionals regarding ongoing care. Care required is interdisciplinary in nature. • Identify community resources for patient and family. Make Allows time for agencies to initiate service. Use of existing referrals at least 3 days before discharge from hospital. community services is effective use of resources. Copyright © 2002 F.A. Davis Company PROTECTION, INEFFECTIVE 77 Child Health NOTE: Infants at risk for this diagnosis are premature infants, infants with family history of hemo - philia or sickle cell anemia, infants whose mothers have a history of drug abuse or HIV, and children who have histories of medication reaction. In infants especially, incubation for HIV depends on ac - quisition time. The infant may be exposed any time during pregnancy, but sero-con/retroversion to a negative HIV status may occur, with a later positive HIV status again. The more symptomatic the mother, the greater the effect in the infant, as a result of constant reinfection in the infant. For infants whose mothers are HIV positive, 26 percent are HIV positive in the first 5 months of life, an additional 24 percent are HIV positive by 12 months of life, and the remaining 50 percent are HIV positive by 2 years of age. Key symptoms are intercurrent infection and weight loss. Other conditions noted include failure to thrive, hepatomegaly, cardiomegaly, lymphoid interstitial pneumonia, chronic diarrhea, car - diomyopathy, encephalopathy, and opportunistic infections. Even tuberculosis may be seen in these infants, with a tendency to progress from primary to miliary phase. In these infants there may be dis - seminated bacille Calmette-Guérin (BCG) infection. It is important to be aware of laboratory studies requiring large amounts of blood to study the course of sero HIV status. This blood drawing is prob - lematic in the already depressed immune and reticuloendothelial systems of these infants. It is imper - ative that these infants not be given live polio vaccine because of their HIV-positive status. ACTIONS/INTERVENTIONS RATIONALES • Maintain monitoring for: Essential monitoring to avoid overwhelming of child’s system by � Observable lesions of ecchymotic nature or evidence of infection, etc. tendency toward bruising � Decreased absorption of nutrients (especially the premature infant because of the possibility of necrotizing enterocolitis) • Provide at least one 30- to 60-min opportunity per day for the Reduces anxiety, fear, and anger, and provides an opportunity for family to ventilate feelings about the specific illness of their teaching. child. • Teach the child and family essential care. Basics of home care for child with diagnosis

of Ineffective Protection. • As applicable, exercise caution for any medications or blood products to be administered. • Provide diversionary therapy according to child’s status, Prevents boredom and restlessness and fosters continued developmental level, and interests. development of child in spite of illness. • Be aware of current frustration with use of DDC Avoid unrealistic hope. Ideally, toxicity is balanced against the need (dideoxycytidine) and AZT (zidovudine) in children. At this to reach therapeutic central nervous system (CNS) dosage levels. time, protocols dictate doses. • Remind the family that current treatment for AIDS is only Avoids unrealistic hope while providing knowledge and support palliative. Be sensitive to the unique nature of this health necessary to deal with a fatal illness. concern for all involved. Promote attention to the need for: � Spiritual and emotional support � Nutritional support � Treatment of HIV-related infections � Administration of IV immune globulin � Treatment of tumors and end organ failure � Chronic pain • Acknowledge potential loss of mother for the infant with HIV, Anticipatory planning will assist in health maintenance in best and plan appropriately for foster care status as indicated. interest of infant in event of need for separation from the mother. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Maintain monitoring for defining characteristics of Ineffective Provides basic knowledge base for planning of care. Protection: � HELLP syndrome (a severe form of pregnancy-induced hypertension): Monitor laboratory results for low platelets (less than 100,000/cc), elevated liver enzymes, elevated SGOT/SGPT, intravascular hemolysis, schistocytes or burr cells on peripheral smear, low hematocrit (Hct) (without evidence of significant blood loss), and hypertension.86,102 (continued) Copyright © 2002 F.A. Davis Company 78 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Other high-risk history in the mother such as history of Allows nursing staff time and information to plan individual care preterm labor, chronic hypertension, sickle cell anemia, and for the mother and her newborn infant. other blood disorders. � Signs and symptoms of infection. � Mother’s history of drug abuse, alcohol abuse, HIV, or Safety of the mother and the infant is of utmost importance. domestic violence. Provides opportunity for assessment of home environment and provision of assistance. Psychiatric Health NOTE: Clients receiving antipsychotic neuroleptic drugs are at risk for development of agranulocyto- sis. This can be a life-threatening side effect and usually occurs in the first 8 weeks of treatment. Any rapid onset of sore throat and fever should be immediately reported and actively treated. Tricyclic an- tidepressants can cause blood dyscrasias with long-term therapy. Initial symptoms of these dyscrasias include fever, sore throat, and aching. ACTIONS/INTERVENTIONS RATIONALES • Immediately report the client’s complaint of sore throat or Alterations could be symptoms of agranulocytosis or blood development of temperature elevation to physician. Institute dyscrasias, which would place the client at risk for infection. nursing actions for hyperthermia (Chap. 3). Prompt recognition and intervention prevent progression and improve client outcome. • Teach the client who has had this type of response to antipsychotic neuroleptics or tricyclic antidepressants that he or she should not take this drug again. • If the client is experiencing severe alterations in thought Client safety is of primary importance. Provides opportunity for processes, provide one-to-one observation until mental status ongoing assessment of the quality of the content of the client’s improves or until the client can again participate in unit activities. thought and provides ongoing reality orientation. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor sensory status at each encounter. Ensure, if necessary, Uncorrected sensory impairments may negatively impact the that sensory-enhancing aids (glasses, contacts, hearing aids) are communication process. clean and functioning. • Monitor for subtle signs of infection, such as new onset of falls, Changes in immune system with aging can cause increased incontinence, confusion, or decreased level of function. potential for infection. Infection may present in an atypical manner in older adults.39 • Teach the client to avoid soaps that may cause dry skin. Dry skin predisposes to potential skin breakdown and loss of protective barrier against pathogens.123 • Initiate measures to maintain skin integrity such as: Intact skin acts as a protective barrier against infection.124 � Using pressure-relieving devices for use in chairs or in bed � Ensuring frequent weight shifting to reduce pressure on vulnerable areas (bony prominences) � Monitoring and documenting skin status with each contact according to care setting and client condition � Avoiding shearing forces that may cause epidermal damage � Prompting client and caregiver to change position frequently to avoid skin integrity problems • Teach clients and/or caregivers need for AIDS testing as AIDS is often undetected in older adults in the early stages appropriate. because of lack of knowledge about risk for the disease and false assumptions that AIDS is not a disease present in older adults.125,126 Copyright © 2002 F.A. Davis Company PROTECTION, INEFFECTIVE 79 Home Health ACTIONS/INTERVENTIONS RATIONALES • Develop, with the client, family, and caregiver, plans for dealing Advance planning improves the response and outcomes in crisis with emergency situations, such as: situations. � Decision making regarding calling ambulance � Decision tree for calling nurse or physician • Assist the client and family to identify learning needs such as: This action describes knowledge required to protect the client and � Universal precautions the family. � How to disinfect surfaces contaminated with blood or body fluids (use 1:10 solution of bleach) � Protective isolation � Proper handwashing � Use of separate razors, toothbrushes, eating utensils, etc. � Proper cooking of food � Avoidance of pet excrement � Avoidance of others with infection � Skin care, oral hygiene, and wound care � Use of protective equipment � Signs and symptoms of infection, fluid and electrolyte imbalance, malnutrition, pathologic changes in behavior, and underlying disease process � CPR and first aid � Hazardous waste disposal, e.g., soiled dressings, needles, or chemotherapy vials � Advanced directive, e.g., living wills and durable power of attorney for health care � Financial and/or estate planning � Symptom management and pain control � Administration of required medications � Nutrition � Care of catheters, IVs, respiratory therapy equipment, etc. � Laundry and dishwashing � Environmental cleanliness • Assist the client and the family to identify resources to meet Involvement of the client and family improves their ability to identified learning needs. identify resources and to function more independently. • Involve the client and family in planning and implementing Involvement of the client and family improves motivation and environmental, social, and family adaptations to protect the outcomes. client. • Plan with the family and client for safe as well as meaningful Provides for activity while protecting the client and family. activities according to the client’s level of functioning and interests. • Assist the client and family in lifestyle adjustments that may be Lifestyle changes often require support. required. Copyright © 2002 F.A. Davis Company 80 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Protection, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate at least X number of measures to increase self-protection? Yes No Record data, e.g., can accurately return- Reassess using initial assessment factors. demonstrate universal precautions and proper disposal of contaminated dressing. May record either RESOLVED or CONTINUE. If RESOLVED, delete nursing diagnosis, expected outcome, target date, and nursing actions. If CONTINUE, change target date and No Is diagnosis validated? nursing actions as necessary. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Yes target date, and nursing actions. Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can use universal precautions but no Did evaluation show another other measures. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SURGICAL RECOVERY, DELAYED 81 Surgical Recovery, Delayed HAVE YOU SELECTED DEFINITION THE CORRECT DIAGNOSIS? An extension of the number of postoperative days required for in- Risk for Infection Risk for infection could be dividuals to initiate and perform on their own behalf activities that maintain life, health and well-being.41 a companion diagnosis and would increase the probability of Delayed Surgical Recovery NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; developing. CLASS 2—ACTIVITY/EXERCISE Ineffective Tissue Perfusion This diagnosis could be the primary diagnosis, because NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; any alteration in tissue perfusion to the CLASS J—PERIOPERATIVE CARE operative site could result in delayed NOC: DOMAIN I—FUNCTIONAL HEALTH; healing. CLASS A—ENERGY MAINTENANCE Impaired Physical Mobility This diagnosis could also be a companion diagnosis or DEFINING CHARACTERISTICS41 could be a contributing factor to the development of Delayed Surgical 1. Evidence of interrupted healing of surgical area (e.g., red, in- Recovery. This diagnosis would interfere durated, draining, immobile) with the necessary postoperative 2. Loss of appetite with or without nausea ambulation. 3. Difficulty in moving about 4. Requires help to complete self-care 5. Fatigue 6. Report of pain or discomfort 7. Postpones resumption of work or employment activities EXPECTED OUTCOME 8. Perception that more time is needed to recover Surgical incision will show no signs or symptoms of delayed heal- ing by [date]. RELATED FACTORS To be developed. TARGET DATES RELATED CLINICAL CONCERNS Because of multiple factors such as age, presence of chronic condi- tions, or a compromised immune system, the target date for this di- 1. Any recent major surgeries agnosis could range from days to weeks. An appropriate initial tar- 2. Recent trauma requiring surgical intervention get date, to measure progress, would be 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with diet therapist for in-depth dietary assessment Adequate, balanced nutrition assists in healing and reducing and planning. Monitor the patient’s food and fluid intake daily. fatigue. • Carefully plan activities of daily living and daily exercise Realistic schedules based on the patient’s input promote schedules with detailed input from the patient. Determine how participation in activities and a sense of success. to best foster future patterns that will maintain optimal sleep-rest patterns without fatigue through planning ADLs with the patient and family. • Assist the patient with self-care as needed. Plan gradual increase Allows the patient to gradually increase strength and tolerance for in activities over several days. activities. • Promote rest at night. Increases quantity and quality of rest and sleep. � Warm bath at bedtime � Warm milk at bedtime � Back massage • Avoid sensory overload or sensory deprivation. Provide Sensory aspects can deplete energy stores. Diversional activities diversional activities. help prevent overload or deprivation by focusing patient’s concentration on an activity he or she personally enjoys. • Instruct the patient in stress reduction techniques. Have patient Mental and physical stress greatly contributes to sense of inability return-demonstrate at least once a day through day of discharge. to resume ADLs. (continued) Copyright © 2002 F.A. Davis Company 82 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Protect the patient from injury and infection. Use standard Protects patient from infection or spread of infection. precautions. • Turn, cough, and deep breathe every 2 h on [odd/even] hour. Mobilizes static pulmonary secretions. • Perform passive exercises or have patient perform active ROM Prevents inadequate tissue perfusion and stasis of blood. exercises every 2 h on [odd/even] hour. • Assist the patient to develop coping skills: � Review past coping behaviors and success or lack of success. Determines what has helped in the past, and determines if the measures are still useful. � Help identify and practice new coping strategies. Allows the patient to practice and become comfortable with skills in a supportive environment. � Challenge unrealistic assumptions or goals. Assists the patient to avoid placing extra stress on self. • Consider cultural and religious norms. Cultural and religious norms influence the perception of “the sick role.” • Collaborate with psychiatric nurse practitioner regarding care. Collaboration helps to provide holistic care. Specialist may help discover underlying events for delayed surgical recovery and assist in designing an alternate plan of care. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all contributing factors, such as diet, altered organic Thorough assessment will best offer ways to address factors that or pathophysiologic functions, medications, environmental are impeding healing. issues, psychological components, and circumstantial issues. • Determine appropriate treatment with attention to unique status Anticipatory planning provides holistic avenues to consider for per client’s situation, with specific attention to medications, recovery. formula or diet, and surgical procedure/expected recovery. • Note specific treatment protocols to satisfy unique healing or Unique protocols will best offer appropriate

healing likelihood surgically related needs for client. when implemented per intended plan. • Reassess every 8 h for progress in healing (wound color, tissue Frequent ongoing assessment provides feedback to assist in status, drainage, and all related parameters). determination of success of plan versus need for consideration of alternate modalities. • Reassess for potential additional delays of recovery as initial Primary delays in surgical recovery may contribute to likelihood of delays are identified. delays to be noted later, with multiple delays made more likely to be noted before greater complications arise. • Assess for other nursing problems that may be identified as Multifactorial problems in recovery are best managed by separation critical to resolution in relation to current surgical delay. and identification according to known etiology and treatment. Women’s Health This nursing diagnosis pertains to women the same as to any other adult, with exception of the following: ACTIONS/INTERVENTIONS RATIONALES AFTER A CESAREAN SECTION • Monitor abdomen at least every 4 h (state times here) for any Monitor the patient for signs and symptoms of incisional and/or distention, redness or swelling at incision site, tenderness, puerperal infection. foul-smelling lochia, or vaginal discharge. • Wash hands each time before and after you or family members Prevents development of nosocomial infection in the infant. handle the baby. • If maternal delay in recovering involves separation from the infant: � Act as a liaison between the family, nursery, and the mother. � Keep the mother informed and reassured about her baby: (1) If the mother is unable to care for the infant, develop a schedule in which the infant is brought to the mother’s room for frequent visiting. (2) Let significant other or chosen family member care for the infant in the mother’s room. (continued) Copyright © 2002 F.A. Davis Company SURGICAL RECOVERY, DELAYED 83 (continued) ACTIONS/INTERVENTIONS RATIONALES (3) If unable to transport the infant to the mother, obtain pictures of infant and set them up where the mother can view them. � Involve other family members in the care of the infant. (1) Prepare the family to take the infant home without the mother. (2) Teach the family, and have them return-demonstrate, care and feeding of the infant. (3) If the mother desires to breastfeed: (a) Collaborate with physician regarding advisability of breastfeeding. (b) Involve lactation consultant to assist mother in pumping and (1) dumping milk if unable to use for infant, or (2) storing milk, if able to use, and sending home with the family. Psychiatric Health Nursing interventions and rationales for this diagnosis are the same as those for Adult Health. Gerontic Health NOTE: The older adult undergoing surgical treatment, either elective or emergency, is at great risk for problems with delayed recovery. Age-related changes in numerous systems and protective mechanisms increase the potential for complications pre-, intra-, and postoperatively. It is not uncommon for older adults to have pre-existing medical disease, atypical signs and symptoms of infection, cardiac or res- piratory problems, and less ability to deal with stressors such as hypoxia, volume depletion, or volume overload. Gerontologic nursing groups are actively designing research-based protocols to ensure “best practices” in caring for older adults. The reader is referred to the work of NICHE (Nurses Improving the Care of the Hospitalized Elderly) at the Hartford Institute for Geriatric Nursing and the University of Iowa Research-Based Protocols developed by the University of Iowa Gerontological Nursing Inter- ventions Research Center.126 ACTIONS/INTERVENTIONS RATIONALES • Determine the client’s mental status upon admission, and Older adults are at risk for developing acute confusion because of monitor the client for signs of acute confusion (delirium). the multiple risk factors they experience (relocation, pain, Document results of mental status determinations in the client’s physiologic changes associated with surgical procedures). record. The Mini-Mental State Exam by Folstein and/or the NEECHAM Confusion Scale are tools commonly used or recommended to determine mental status.127 • Initiate protocol (if available in your facility) for interventions Delays in determining the presence of acute confusion may lead to addressing care of the acutely confused client if mental status extended hospital stays, decreases in functional status, and nursing changes warrant such action. home placement for older adults. • Manage postoperative acute pain aggressively to assist clients in Older adults and some health care providers may have concerns recovery from the effects of surgery. Teach clients and family or regarding use of pain medication. Some older adults may have significant others the benefits of adequate pain control in the fears of becoming addicted to medications. Health care providers recuperative process. Pain management can promote early may be reluctant to medicate older adults because of concerns ambulation, facilitate effective coughing and deep breathing, about overdosing or oversedating older clients.128,129 and decrease postoperative complications. • Plan caregiving activities to avoid stressing the client with Physiologic reserves are decreased with aging. Too many demands prolonged duration or intensity of activity. can lead to increased fatigue and decreased ability to tolerate mobility efforts and postoperative activities to improve respiratory and cardiovascular status. • Monitor for evidence of poor wound healing. Medications, poor nutritional status, systemic disease, and a history of smoking can have a negative effect on the normal wound repair response.130 • Arrange for a nutrition consult if the client shows evidence of Alterations in nutrition, such as protein-calorie malnutrition or altered nutritional status. nutrient deficiencies, can affect wound healing. • Refer older adults for evaluation of possible depression, especially if declining functional ability is noted. Older adults who have depressive symptoms have negative postoperative outcomes.131,132 Copyright © 2002 F.A. Davis Company 84 HEALTH PERCEPTION—HEALTH MANAGEMENT PATTERN Home Health ACTIONS/INTERVENTIONS RATIONALES • Educate the client, family members, and potential caregivers Allows the family to participate in care and prevents infection or how to care for the wound appropriately and have them exacerbation of existing infection. demonstrate proper wound care. • Assist the client and caregivers in obtaining necessary supplies Maximizes the client and caregiver’s ability to provide appropriate for appropriate wound care. wound care. • Instruct the client and caregivers in signs and symptoms of Prevents further morbidity. infection, hemorrhage, and dehiscence, as well as how and when to seek medical care. • Educate the client, family members, and potential caregivers of Treats existing infection and prevents possible superinfection. the importance of taking all antibiotics as prescribed until the regimen is complete. • Encourage the client to eat small frequent meals that are high in Allows maximum nutrition without discomfort from large meals. calories and protein. • Weigh the client twice weekly. Ensures that weight loss is not excessive. • Encourage the client to identify times of day when fatigue is Allows the client some control of activities. worse, and space activities around the times when they are less fatigued. • Assist the client in obtaining durable medical equipment for the Makes self-care activities less tiring. home (e.g., bedside commodes and shower chairs) until the fatigue improves. • Encourage the client to rest before scheduled activities. May help avoid exacerbation of the fatigue. • Encourage the client to participate in walking activity as Fatigue seems to show improvement with walking programs. tolerated. • Encourage the client and caregivers to adhere to a Keeps pain at a tolerable level and avoids highs and lows in pain round-the-clock analgesic regimen rather than using intensity. medications on a prn basis until pain is controlled. • Actively listen to the client and family members’ concerns about Allows verbalization of frustration and aids in realistic planning for delayed recovery and provide honest answers about the client’s the future. progress. • Assist the client in obtaining letters and/or documentation as Helps eliminate a source of anxiety. needed for employers regarding extended recovery time. Copyright © 2002 F.A. Davis Company SURGICAL RECOVERY, DELAYED 85 Surgical Recovery, Delayed FLOWCHART EVALUATION: EXPECTED OUTCOME Does surgical incision show any signs or symptoms of delayed healing? Yes No Reassess using initial assessment factors. Record data, e.g., incision line clear and dry, no signs of inflammation. Record RESOLVED. Delete nursing diagnosis, expected outcomes, target date, and nursing actions. Is diagnosis validated? Did evaluation show another Yes No problem had developed? Record data, e.g., redness and swelling noted along suture line. Approximately 20 cc of purulent Yes No drainage noted. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company CHAPTER 3 Nutritional-Metabolic Pattern 1. ADULT FAILURE TO THRIVE 92 13. INFANT FEEDING PATTERN, 2. ASPIRATION, RISK FOR 97 INEFFECTIVE 150 3. BODY TEMPERATURE, IMBALANCED, 14. NAUSEA 153 RISK FOR 102 15. NUTRITION, IMBALANCED, 4. BREASTFEEDING, EFFECTIVE 107 LESS THAN BODY 5. BREASTFEEDING, REQUIREMENTS 157 INEFFECTIVE 110 16. NUTRITION, IMBALANCED, MORE 6. BREASTFEEDING, THAN BODY REQUIREMENTS, RISK INTERRUPTED 115 FOR AND ACTUAL 166 7. DENTITION, IMPAIRED 119 17. SWALLOWING, IMPAIRED 173 8. FLUID VOLUME, DEFICIENT, RISK FOR 18. THERMOREGULATION, AND ACTUAL 123 INEFFECTIVE 178 9. FLUID VOLUME, EXCESS 129 19. TISSUE INTEGRITY, IMPAIRED 181 10. FLUID VOLUME, IMBALANCED, A. Skin Integrity, Impaired, Risk for RISK FOR 136 and Actual 11. HYPERTHERMIA 140 B. Oral Mucous Membrane, Impaired 12. HYPOTHERMIA 145 Pattern Description a. Yes (Imbalanced Nutrition, More Than Body Requirements, Risk for or Actual; Fluid Volume Excess; Imbalanced Body This pattern focuses on food and fluid intake, the body’s use of this Temperature, Risk for; Imbalanced Fluid Volume, Risk for) intake (metabolism), and problems that might influence intake. b. No Problems in this pattern may arise from a physiologic, psychologi - 2. Does the patient weigh less than the recommended range for his cal, or sociologic base. Physiologic problems may be primary in na - or her height, age, and sex? ture, for example, vitamin deficiency, or they may arise secondary a. Yes (Imbalanced Nutrition, Less Than Body Requirements; De- to another pathophysiologic state such as a peptic ulcer. Psycho - ficient Fluid Volume, Risk for or Actual; Imbalanced Body Tem- logical factors, such as stress, may result in an alteration, such as perature, Risk for; Adult Failure to Thrive; Impaired Dentition) overeating or anorexia nervosa, in the nutritional-metabolic pat - b. No tern. Sociologic factors, for example, low income, inadequate stor- 3. Have the patient describe a typical day’s intake of both food and age, social isolation, and cultural food preferences, may result in an fluid, including snacks and the pattern of eating. Is the patient’s altered nutritional-metabolic state. food intake above the average for his or her age, sex, height, A popular saying is “You are what you eat.” This is a truism; what weight, and activity level? we eat is converted to our cellular structure and affects its func - a. Yes (Imbalanced Nutrition, More Than Body Requirements, tioning. The nutritional-metabolic pattern allows us to look at the Risk for or Actual) whole of this relationship. b. No 4. Is the patient’s food intake below the average for his or her age, sex, height, weight, and activity level? Pattern Assessment a. Yes (Imbalanced Nutrition, Less Than Body Requirements; 1. Weigh the patient. Does the patient weigh more than the rec- Adult Failure to Thrive; Impaired Dentition) ommended range for his or her height, age, and sex? b. No 86 Copyright © 2002 F.A. Davis Company CONCEPTUAL INFORMATION 87 5. Is the patient’s fluid intake sufficient for his or her age, sex, Conceptual Information height, weight, activity level, and fluid output? a. Yes The nutritional-metabolic pattern requires looking at four separate b. No (Deficient Fluid Volume, Risk for or Actual; Imbalanced but closely aligned aspects: nutrition, fluid balance, tissue integrity, Body Temperature, Risk for; Imbalanced Fluid Volume, and thermoregulation. All four functionally interrelate to maintain Risk for) the integrity of the overall nutritional-metabolic functioning of the 6. Does the patient show evidence of edema? body. a. Yes (Fluid Volume Excess; Imbalanced Fluid Volume, Risk for) Food and fluid intake provides carbohydrates, proteins, fats, vi- b. No tamins, and minerals, which are metabolized by the body to meet 7. Is the patient’s gag reflex present? energy needs, maintain intracellular and extracellular fluid bal- a. Yes ances, prevent deficiency syndromes, and act as catalysts for the b. No (Impaired Swallowing; Risk for Aspiration) body’s biochemical reactions.1 8. Does the patient cough or choke during eating? a. Yes (Impaired

Swallowing; Risk for Aspiration) NUTRITION b. No 9. Assess the patient’s mouth, eyes, and skin. Are these assessments Nutrition refers to the intake, assimilation, and use of food for en- within normal limits (e.g., no lesions, soreness, or inflamed areas)? ergy, maintenance, and growth of the body.2 Assisting the patient a. Yes in maintaining a good nutritional-metabolic status facilitates health b. No (Impaired Tissue Integrity; Impaired Oral Mucous promotion and illness prevention and provides dietary support in Membrane) illness.1 10. Assess the patient’s teeth. Are teeth within normal limits? Swallowing is associated with the intake of food or fluids. Swal- a. Yes lowing is a complex activity that integrates sensory, muscular, and b. No (Impaired Dentition) neurologic functions that generally occur in four phases: (1) oral 11. Are intake and output, skin turgor, and weight vacillating? preparatory phase, during which the food is chewed, mixed with a. Yes (Imbalanced Fluid Volume, Risk for) saliva, and prepared for digestion; (2) oral phase, during which food b. No is moved backward past the hard palate and downward to the phar- 12. Is the patient able to move freely in bed? Ambulates easily? ynx; (3) pharyngeal phase, when the larynx closes and the food en- a. Yes ters the esophagus; and (4) esophageal phase, during which the food b. No (Impaired Tissue Integrity; Impaired Skin Integrity, passes through the esophagus, in peristaltic movement, to the Risk for or Actual) stomach. The first two phases are voluntarily controlled, and the 13. Review the patient’s temperature measurement. Is the temper- last two phases are involuntarily controlled. ature within normal limits? Many factors affect a person’s nutritional status, such as food a. Yes availability and food cost; the meaning food has for an individual; b. No (Ineffective Thermoregulation; Hyperthermia; Hypother- cultural, social, and religious mores; and physiologic states that mia) might alter a person’s ability to eat.3 14. Is the patient’s temperature above normal? In essence, we are initially concerned with the adequacy or in- a. Yes (Ineffective Thermoregulation; Hyperthermia) adequacy of the patient’s nutritional state. If the diet is adequate, b. No there is no major reason for concern, but we must be sure that all 15. Is the patient’s temperature below normal? are defining “adequacy” in a similar manner. Most people probably a. Yes (Ineffective Thermoregulation; Hypothermia) define an adequate diet as lack of hunger; however, professionals b. No look at an adequate diet as being one in which nutrient intake bal- 16. Is the patient exhibiting signs or symptoms of infection? Vaso- ances with body needs. The diet is adequate if it meets either min- constriction? Vasodilation? Dehydration? imum daily requirements (MDR) or recommended dietary al- a. Yes (Imbalanced Body Temperature, Risk for) lowances (RDA) standards. The MDR standards are lower for b. No nutrient amounts than the RDA standards, but they do provide 17. Ask the patient: “Do you have any problems swallowing food? enough nutrients to prevent deficiency problems. The RDA stan- Fluids?” dards are the ones more widely used and are the ones that provide a. Yes (Impaired Swallowing; Risk for Aspiration) the well-known “basic four food groups.”3 The guidelines incorpo- b. No rating the basic four food groups were recently revised and are now 18. Does the patient report chronic health problems? represented as the Food Guide Pyramid, which is currently the best a. Yes (Adult Failure to Thrive) standard to use in assessing dietary adequacy. The revised standard b. No calls for: 19. Is the patient complaining of being nauseated? Bread, cereals, rice, pasta Enriched or whole-grain products; a. Yes (Nausea) 6–11 servings per day b. No Vegetables 3–4 servings per day The next questions pertain only to a mother who is breastfeeding. Fruits 2–4 servings per day Milk, yogurt, cheese Milk, ice cream, yogurt, and cheese; 20. Weigh the infant. Is his or her weight within normal limits for 2–3 servings per day his or her age? Meat, poultry, fish, dry 2–3 servings of 2–3 oz per day a. Yes (Effective Breastfeeding) beans, eggs, nuts b. No (Ineffective Breastfeeding) Fats, oils, sugars Used sparingly 21. Ask the patient: “Do you have any problems or concerns about breastfeeding?” NOTE: Many adults may be lactose intolerant. Lactase enzymes a. Yes (Ineffective Breastfeeding) are now available over-the-counter as a digestive aid for lactose b. No (Effective Breastfeeding) intolerance. Copyright © 2002 F.A. Davis Company 88 NUTRITIONAL-METABOLIC PATTERN An inadequate nutritional state may be reflective of intake (calo- Electrolytes are either positively or negatively charged particles ries), use of the intake (metabolism), or a change in activity level. (ions). The major positively charged electrolytes (cations) are Underweight and overweight are the most commonly seen condi- sodium (the main extracellular electrolyte), potassium (the most tions that reflect alteration in nutrition.4 common intracellular electrolyte), calcium, and magnesium. The Underweight can be caused by inadequate intake of calories. In major negatively charged electrolytes (anions) are chloride, bicar- some instances, the intake is within RDA, but there is malabsorp- bonate, and phosphate. The electrolyte compositions of the two ex- tion of the intake. The malabsorption or inadequate intake can be tracellular compartments (interstitial and intravascular) are nearly due to physiologic causes (pathophysiology), psychological causes identical. The intracellular fluid contains the same number of elec- (anorexia, bulimia), or cultural factors (lack of resources or reli- trolytes as the extracellular fluid does, but the intracellular elec- gious proscriptions).4 trolytes carry opposite electrical charges from the electrolytes in the Special notice needs to be given to the maternal nutritional needs extracellular fluid. This difference between extracellular and intra- during the postpartum period. New mothers need optimal nutri- cellular electrolytes is necessary for the electrical activity of nerve tion to promote healing of the tissues traumatized during labor and and muscle cells.1,3 Therefore, the electrolytes help regulate cell delivery, to restore balance in fluid and electrolytes created by all functioning as well as the fluid volume in each compartment. the rapid changes in the body, and, if the mother is breastfeeding, Usually the body governs intake through thirst and output to produce adequate amounts of milk containing fluid and nutri- through increasing or decreasing body fluid excretion via the kid- ents for the infant.5 neys, GI tract, and respiration. Because of the way the body governs The breastfeeding woman can generally meet the nutritional intake and output, in addition to the effects of pathophysiologic needs of herself and her infant through adequate dietary intake of conditions such as shock, hemorrhage, diabetes, and vomiting on food and fluids; however, because the energy demand is greater intake and output, the patient may enter a state of metabolic aci- during lactation, RDA standards recommend an additional 500 dosis or alkalosis. cal/day above the norm to prevent catabolism of lean tissue.5 Stud- Acid-base balance reflects the acidity or alkalinity of body fluids ies have shown that the caloric intake of breastfeeding women and is expressed as the pH. In essence, the pH is a function of the range from 2460 to 3060 Kcal/day and that successful breastfeed- carbonic acid:bicarbonate ratio.3 Acid-base balance is regulated by ing may be related to the nutritional status during pregnancy.6 chemical, biologic, and physiologic mechanisms. The chemical reg- An overweight condition is rarely due to a physiologic distur- ulation involves buffers in the extracellular fluid, whereas the bio- bance, although a genetic predisposition may exist. Overweight is logic regulation involves ion exchange across cell membranes. The most commonly due to an imbalance between food and activity physiologic regulation is governed in the lungs by carbon dioxide habits (i.e., increased intake and decreased activity).4 However, re- excretion and in the kidneys through metabolism of bicarbonate, search is indicating there is a metabolic set point, and in actuality, acid, and ammonia.1 overweight people may be eating less than normal-weight people. Metabolic acidosis is caused by situations in which the cellular Either underweight or overweight may be a sign of malnutrition production of acid is excessive (e.g., diabetic ketoacidosis), high (inadequate nutrition), with the result that the patient exhibits doses of drugs (e.g., aspirin) have to be metabolized, or excretion signs and symptoms of less than body requirements or more than of the produced acid is impaired (e.g., renal failure).3 Weight re- body requirements. In either instance, the nurse must assess the pa- duction practices (fad diets or diuretics) can contribute to the de- tient carefully for his or her overall concept of malnutrition. velopment of acidosis, as can chemical substance abuse.1 Fluid volume is affected by regulatory mechanisms, body fluid FLUID VOLUME loss, or increased fluid intake. Because fluid volume is so readily af- fected by such a variety of factors, continuous assessment for alter- Fluid volume incorporates the aspects of actual fluid amount, elec- ations in fluid volume must be made. trolytes, and metabolic acid-base balance. Regardless of how much or how little a patient’s intake or how much or how little a patient’s TISSUE INTEGRITY output is, the fluid, electrolyte, and metabolic acid-base balances are maintained within a relatively narrow margin. This margin is es- Nutrition and fluid are vitally important to tissue maintenance and sential for normal functioning in all body systems, and so it must repair. Underlying tissues are protected from external damage by receive close attention in providing care. the skin and mucous membranes. Thus, the integrity of the skin is Approximately 60 percent of an adult’s weight is body fluid (liq- extremely important in the promotion of health because the skin uid plus electrolytes plus minerals plus cells), and approximately and mucous membranes are the body’s first line of defense. The 75 percent of an infant’s weight is body fluid. These various parts skin also plays a role in temperature regulation and in excretion. of body fluid are taken in daily through food and drink and are The skin and mucous membranes act as protection through their formed through the metabolic activities of the body.1,3 The body abundant supply of nerve receptors that alert the body to the ex- fluid distribution includes intracellular (within the cells), interstitial ternal environment (i.e., temperature, pressure, or pain). The skin (around the cells), and intravascular (in blood cells) fluids. The and mucous membranes also act as barriers to pathogens, thus pro- combination of interstitial and intravascular is known as extracellu- tecting the internal tissues from these organisms.3 lar (outside the cells) fluid. Distribution of body fluid is influenced The skin’s superficial blood vessels and sweat glands (eccrine and by both the fluid volume and the concentration of electrolytes. apocrine) assist in thermoregulation. As the body temperature rises, Body fluid movement, between the compartments, is constant and the superficial blood vessels dilate and the sweat glands increase se- occurs through the mechanisms of osmosis, diffusion, active trans- cretion. These two actions result in increased perspiration, which, port, and osmotic and hydrostatic pressure.1,3 through evaporation, cools the body. During instances of excessive Body fluid balance is regulated by intake (food and fluid), out- perspiration, water, sodium chloride, and nonprotein nitrogen are put (kidney, gastrointestinal [GI] tract, skin, and lungs), and hor- excreted through the skin; this affects fluid volume and osmotic mones (antidiuretic hormones, glucocorticoids, and aldosterone). balance. As the body temperature drops, the opposite reactions oc- The largest amount of fluid is located in the intracellular compart- cur; there is vessel constriction and decreased sweat gland secretion ment, with the volume of each compartment being regulated pre- so that body heat is retained internally. dominantly by the solute (mainly the electrolytes). To fulfill their protective function of the underlying tissues, the Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 89 skin and mucous membranes must be intact. Any change in skin or ally no developmental considerations of the act of swallowing, be- mucous membrane integrity can allow pathogen invasion and will cause it is a reflex. also allow fluid and electrolyte loss. Skin and mucous membrane The normal process for swallowing involves both the epiglottis integrity relies on adequate nutrition and removal of metabolic and the true vocal cords. These two structures move together to wastes (internally and externally), cleanliness, and proper posi- close off the trachea and to allow saliva or solid and liquid foods to tioning. One study7 found that the length of a surgical procedure pass into the esophagus. The respiratory system is thus protected and extracorporeal circulation were associated with increased risk from

foreign bodies. of skin breakdown for elective procedures. In emergency surgical Salivation is adequate at birth to maintain sufficient moisture in settings or in cases of patients in poor health (very elderly and med- the mouth. However, maturation of many salivary glands does not ically indigent), age and serum albumin levels might also be pre- occur until the third month and corresponds with the baby’s learn- dictive of increased risk for skin breakdown.7 Any factor that com- ing to swallow at other than a reflex level.9 Tooth eruption begins promises nutrition, fluid, or electrolyte balance can result in at about 6 months of age and stimulates saliva flow and chewing. impairment of skin or mucous membrane integrity or, at least, a The infant has a small amount of the enzyme ptyalin, which breaks high risk for impairment of skin integrity or mucous membrane in- down starches. tegrity. Water constitutes the greatest proportion of the infant’s body weight. Approximately 75 to 78 percent of an infant’s body weight THERMOREGULATION is water, with about 45 percent of this water found in the extracel- lular fluid. The newborn infant loses significant water through in- Thermoregulation refers to the body’s ability to adjust its internal sensible methods (approximately 35 to 45 percent) because of rel- core temperature within a narrow range. The core temperature atively greater body surface area to body weight. The respiratory must remain fairly constant for metabolic activities and cellular me- rate of an infant is approximately two times that of the adult; there- tabolism to function for the maintenance of life. The core temper- fore, the infant is also losing water through insensible loss from the ature rarely varies as much as 2F. In fact, the range of temperature lungs. The newborn also loses water through direct excretion in the that is compatible with life ranges only from approximately 90 to urine (50 to 60 percent) and through fairly rapid peristalsis as a re- 104F. sult of the immaturity of the GI tract. Both the hypothalamus and the thyroid gland are involved in The newborn is unable to concentrate urine well, so is more sen- thermoregulation. The hypothalamus regulates temperature by re- sitive to inadequate fluid intake or uncompensated water loss.10 sponding to changes in electrolyte balances. Both the extracellular The body fluid reserve of the infant is less than that of the adult, cations, sodium and calcium, affect the action potential and depo- and because the infant excretes a greater volume per kilogram of larization of cells. When there is an imbalance of sodium and cal- body weight than the adult, infants are very susceptible to deficient cium within the hypothalamus, hypothermia or hyperthermia can fluid volume. The infant needs to consume fluids equal to 10 to 15 result. The thyroid glands regulate core body temperature by in- percent of body weight. Fluid and electrolyte requirements for the creasing or decreasing metabolic activities and cellular metabolism, newborn are 70 to 100 mL/kg per 24 hours, 2 mEq of sodium and thus altering heat production. potassium per kilogram per 24 hours, and 2 to 4 mEq of chloride Many factors influence thermoregulation. The skin has previ- per kilogram per 24 hours. ously been mentioned as a thermoregulatory organ. Heat is gained The kidney function of the infant does not reach adult levels un- or lost to the environment by evaporation, conduction, convection, til 6 months to 1 year of age.10 The functional capacity of the kid- and radiation. Evaporation occurs when body heat transforms the neys is limited, especially during stress. In addition, the glomeru- liquid on a person’s skin to vapor. Conduction is the loss of heat to lar filtration rate is low, tubular reabsorption or secretory capacity a colder object through direct contact. When heat is lost to the sur- is limited, sodium reabsorption is decreased, and the metabolic rate rounding cool air, it is called convection. Radiation occurs when heat is higher. Therefore, there is a greater amount of metabolic wastes is given off to the environment, helping to warm it. to be excreted. The infant’s kidney is less able to excrete large loads A person generally loses approximately 70 percent of heat from of solute-free water than the more mature kidney.11 radiation, convection, and conduction. Another 25 percent is lost Feeding behavior is important not only for fluid but also for food. through insensible mechanisms of the lungs and evaporation from The caloric need of the infant is 117 cal per kilogram of body the skin, and about 5 percent is lost in urine and feces. When the weight.4 body is able to produce and dissipate heat within a normal range, Breast milk contains adequate nutrients and vitamins for ap- the body is in heat balance.8 proximately 6 months of life. Some bottle formulas are overly high in carbohydrates and fat (especially cholesterol), which may lead to SUMMARY a potential for increasing fat cells. The introduction of solid foods should not occur until 4 to 6 The interrelationship of nutrition, fluid balance, thermoregulation, months of age. Studies have indicated that there is a relationship and tissue integrity explains the nursing diagnoses that have been ac- between the early introduction of solid food (younger than 4 cepted in the nutritional-metabolic pattern. Indeed, if there is an al- months of age) and overfeeding of either milk or food, leading to teration in any one of these four factors, it would be wise for the nurse infant and adult obesity.4 The infant should be made to feel secure, to assess the other three factors to ensure a complete assessment. loved, and unhurried at feeding time. Skin contact is very impor- tant for the infant for both physiologic and psychological reasons. Developmental Considerations The skin of an infant is functionally immature, and thus the baby is more prone to skin disorders. Both the dermis and the epidermis INFANT are loosely connected, and both are relatively thin, which easily leads to chafing and rub burns.9 Epidermal layers are permeable, Swallowing is a reflex present before birth, because during in- resulting in greater fluid loss. Sebaceous glands, which produce se- trauterine life the fetus swallows amniotic fluid. Following the tran- bum, are very active in late fetal life and early infancy, causing milia sition to extrauterine life, the infant learns very rapidly (within 12 and “cradle cap,” which goes away at about 6 months of age. Dry, to 24 hours) to coordinate sucking and swallowing. There are re- intact skin is the greatest deterrent to bacterial invasion. Sweat Copyright © 2002 F.A. Davis Company 90 NUTRITIONAL-METABOLIC PATTERN glands (eccrine or apocrine) are not functional in response to heat is better able to tolerate fluid loss through diarrhea. The 2- to 3- and emotional stimuli until a few months after birth, and their func- year-old needs 1100 to 1200 mL (4 to 5 8-oz glasses) of fluid every tion remains minimal through childhood. The inability of the skin 24 hours, whereas the preschooler needs 1300 to 1400 mL of flu- to contract and shiver in response to heat loss causes ineffective ids every 24 hours. thermal regulation.4 Also, the infant has no melanocytes to protect The caloric need in the toddler is 1000 cal/day or 100 cal/kg at against the rays of the sun. This is true of dark-skinned infants as 1 year and 1300 to 1500 cal/day at 3 years. A child should not be well as light-skinned infants. forced to “clean the plate” at mealtime, and food should not be Core body temperature in the infant ranges from 97 to 100F. viewed as a reward or punishment. Instead, caloric intake should Temperature in the infant fluctuates considerably because the reg- be related to the growing body and energy expenditures. ulatory mechanisms in the hypothalamus are not fully developed. The caloric need of the preschooler is 85 cal/kg. Eating assumes (It is not considered abnormal for the newborn infant to lose 1 to increasing social significance and continues to be an emotional as 2F immediately after birth.) The infant is unable to shiver to pro- well as a physiologic experience.4 Frustrating or unsettled meal- duce heat, nor does the infant have much subcutaneous fat to in- times can influence caloric intake, as can manipulative behavior on sulate the body. However, the infant does have several protective the part of the child or parent. The child may also be eating empty mechanisms by which he or she is able to conserve heat to keep the calories between meals. body temperature fairly stable. These mechanisms include vaso- In the toddler, functional maturity of skin creates a more effec- constriction so that heat is maintained in the inner body core, an tive barrier against fluid loss; the skin is not as soft as the infant’s, increased metabolic rate that increases heat production, a closed and there is more protection against outside bacterial invasion. The body position (the so-called fetal position) that reduces the amount skin remains dry because sebum secretion is limited. Eccrine sweat of exposed skin, and the metabolism of adipose tissue. gland function remains limited, eczema improves, and the fre- This particular adipose tissue is called “brown fat” because of the quency of rashes declines. rich supply of blood and nerves. Brown fat composes 2 to 6 percent Skin, as a perceptual organ, experiences significant development of body weight of the infant. Brown fat aids in adaptation of the during this period. Children like to “feel” different objects and tex- thermoregulation mechanisms.9 The ability of the body to regulate tures and like to be hugged. Melanin is formed during these years, temperature at the adult level matures at approximately 3 to 6 and thus the toddler, preschooler, and school-age child are more months of age. protected against sun rays.9 In addition, small capillaries in the periphery become more ca- TODDLER AND PRESCHOOLER pable of constriction and thus thermoregulation. Also, the child is able to sense and interpret that he or she is hot or cold and can vol- By the end of the second year, the child’s salivary glands are adult untarily do something about it. size and have reached functional maturity.9 The toddler is capable of chewing food, so it stays longer in his or her mouth, and the sali- SCHOOL-AGE CHILD vary enzymes have an opportunity to begin breaking down the food. The saliva also covers the teeth with a protective film that The child at this age begins losing baby teeth as permanent teeth helps prevent decay. Drooling no longer occurs because the toddler erupt. The child should not be evaluated for braces until after all 6- easily swallows saliva. year molars have erupted. The permanent teeth are larger than the Dental caries occur infrequently in children younger than 3 baby teeth and appear too large for the small face, causing some em- years; but rampant tooth decay in very young children is almost al- barrassment. Good oral hygiene is important. ways related to prolonged bottle feeding at nap time and bedtime For the school-age child, the percentage of total body water to (bottle mouth syndrome). The toddler should be weaned from the total body weight continues to decrease until about 12 years of age bottle or at least not allowed to fall asleep with the bottle in her or when it approaches adult norms.14 Extracellular fluid changes from his mouth.12 Parents should be taught that the adverse effects of 22 percent at 6 years to 17.5 percent at age 12 as a result of the pro- bedtime feeding are greater than thumb sucking or the use of paci- portion of body surface area to mass, increasing muscle mass and fiers. connective tissue, and increasing percentage of body fat. Affected teeth remain susceptible to decay after nursing stops. If Water is needed for excretion of the solute load. Balance is main- deciduous teeth decay and disintegrate early, spacing of the per- tained through mature kidneys, leading to mature concentration of manent teeth is affected, and immature speech patterns develop. urine and acidifying capacities. Fluid requirements can be calcu- Discomfort is felt and emotional problems may result.12 lated by height, weight, surface area, and metabolic activity. The The first dental examination should be between the ages of 18 school-age child needs approximately 1.5 to 3 quarts of fluid a

day. and 24 months. Dental hygiene should be started when the first Additionally, the child needs a slightly positive water balance. The tooth erupts by cleansing the teeth with gauze or cotton moistened electrolyte values are similar to those for the adult except for phos- with hydrogen peroxide and flavored with a few drops of mouth- phorus and calcium (because of bone growth).14 wash. After 18 months, the child’s teeth may be brushed with a soft The caloric need of the school-age child is greater than that of an or medium toothbrush.12 Fluoride supplements are believed to adult (approximately 80 cal/kg or 1600 to 2200 cal/day). The ages prevent cavities. of 10 to 12 reflect the peak ages of caloric and protein needs of the In the toddler, there is beginning to be the appropriate propor- school-age child (50 to 60 cal/kg per day) because of the acceler- tion of body water to body weight (62 percent water).13 The extra- ated growth, muscle development, and bone mineralization. “The cellular fluid is about 26 percent, whereas the adult has about 19 school age child reflects the nutritional experiences of early child- percent extracellular fluid. Toddlers have less reserve of body fluid hood and the potential for adulthood.”4 than adults and lose more body water daily, both from sensible and insensible loss. This age group is highly predisposed to fluid im- ADOLESCENT balances.14 These imbalances relate to the fact that the kidney still is immature, so water conservation is poor, and the toddler still has By age 21, all 32 permanent teeth have erupted. The adolescent an increased metabolic rate and therefore greater insensible water needs frequent dental visits because of cavities and also for ortho- loss than the adult. However, GI motility slows, so this age group dontic work that may be in progress. There is a growth spurt and Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 91 sexual changes. A total increase in height of 25 percent and a dou- has on health status and quality of life.19,20 Since the early 1990s, bling of weight are normally attained.15 Muscle mass increases and many states and organizations working with older adults have be- total body water declines with increasing sexual development.16 gun nutritional screening to identify those at high risk for poor nu- The adolescent needs 34 to 45 cal/kg per day and tends to have eat- trition. The Nutrition Screening Initiative (NSI) program encour- ing patterns based on external environmental cues rather than ages use of a 10-item checklist entitled “DETERMINE” to identify hunger. Eating becomes more of a social event. There is a high at-risk elders. The checklist is easily administered and results in a probability of eating disorders such as anorexia and bulimia arising score ranging from 0 (lowest risk) to 21 (highest risk).21 Scores of during this age period. 4 or more on the checklist usually indicate that the older adult The basal metabolic rate increases, lung size increases, and max- should undergo further nutritional evaluation. Many older adults imal breathing capacity and forced expiratory volume increase, experience aging changes that can affect nutritional status. Older leading to increased insensible loss of fluid through the lungs. To- adults also experience risk factors, such as polypharmacy, social tal body water decreases from 61 percent at age 12 to 54 percent isolation, low income, altered functional status, loneliness, and by age 18 as a result of an increase in fat cells. Fat cells do not have chronic and acute diseases, that impact nutritional status.22 as much water as tissue cells.16 The water intake need of the ado- Older adults may experience changes in the mouth that can af- lescent is about 2200 to 2700 mL per 24 hours. fect nutrition. Tooth decay, tooth loss, degeneration of the jaw Sebaceous glands become extremely active during adolescence bone, progressive gum regression, and increased reabsorption of and increase in size. Eccrine sweat glands are fully developed and the dental arch can make chewing and eating a difficult task for the are especially responsive to emotional stimuli (and are more active older adult if good dental health has not been maintained.23 Re- in males); and apocrine sweat glands also begin to secrete in re- duced chewing ability, problems associated with poorly fitting den- sponse to emotional stimuli.17 Stopped-up sebaceous glands lead tures, and a decrease in salivation secondary to disease or medica- to acne, and the adolescent’s skin is usually moist. tion effects compound nutritional problems for older adults.24 Aging causes atrophy of the olfactory organs, and with diminished YOUNG ADULT smell often comes decreased enjoyment of foods and decreased consumption.25 Research continues to evolve concerning taste dis- The amount of ptyalin in the saliva decreases after 20 years of age; crimination in older adults. More recent studies support limited otherwise the digestive system remains fully functioning. The ap- changes in taste associated with aging when healthy, nonmedicated pearance of “wisdom teeth,” or third molars, occurs at 20 to 21 adults are sampled. The impact of medications, poor oral hygiene, years. There are normally four third molars, although some indi- or cigarette smoking may cause older adults to complain of an un- viduals may not fully develop all four. Third molars can create pleasant taste in their mouth called dysgeusia.26 problems for the individual. Eruptions are unpredictable in time Changes in olfaction and decreased salivation secondary to dis- and presentation, and molars may come in sideways or facing any ease or medications can influence the taste of food. When com- direction. This can force other teeth out of alignment, which makes pounded by gum disease, poor teeth, or dentures, problems with chewing difficult and painful. Often these molars need to be re- food intake can occur. The number of older adults who are edentu- moved to prevent irreparable damage to proper occlusion of the lous (without teeth) is gradually declining and is estimated to be ap- jaws. Even normally erupting third molars may be painful. The proximately 37 percent of adults 70 years of age or older.23 Caries, young adult must see a dentist regularly. especially occurring on the crowns of the tooth, occur in more than Total body water in the young adult is about 50 to 60 percent. 95 percent of the elderly population.23 Older adults are especially There is a difference between males and females because of the dif- vulnerable to oral carcinomas.27 ference in the number of fat cells. Most water in the young adult is Total body water of the older adult is about 45 to 50 percent. intracellular, with only about 20 percent of fluid being extracellu- Older adults have problems tolerating extremes of temperature. Ag- lar. Growth is essentially finished by this developmental age. ing results in skin changes such as dryness and wrinkling. Skin as- sessment for alterations in fluid volume must be carefully inter- ADULT preted. Skin turgor assessment should be done on the abdomen, sternum, or the forehead. Skin turgor is not a reliable indicator Ptyalin has sharply decreased by age 60 as well as other digestive en- of hydration status in older adults. Assessment should focus zymes. Total body water is now about 47 to 54.7 percent. Diet and on tongue dryness, furrows in the tongue, confusion, dry mucous activity indirectly influence the amount of body water by directly al- membranes, “sunken” appearance of the eyes, or difficulty tering the amount of adipose tissue. In the adult, the activity level is with speech.28 Older adults also have a diminished thirst sensation stable or is beginning to decline. The basal metabolic rate gradually secondary to changes in brain osmoreceptors, thus thirst is not decreases along with a reduced demand for calories. The adult needs readily triggered in older adults.27 Changes in blood volume are to reduce calorie intake by approximately 7.5 percent.18 minimal. Serum protein (albumin) production is decreased, but Tissues of the integumentary system maintain a healthy, intact, globulin is increased. glowing appearance until age 50 to 55 if the individual is receiving Aging changes do bring about changes in nephrotic tubular func- adequate vitamins, minerals, other nutrients, and fluids and main- tion, which affects removal of water, urine concentration, and di- tains good personal hygiene. Wrinkles do become more noticeable, lution. This leads to a decrease in specific gravity and urine osmo- however, and body water (from integumentary tissues) decreases, larity. There is a decrease in bladder capacity, often leading to leading to thinner, drier skin that bruises much more easily. Fat in- nocturia. With the change in bladder capacity, older adults may creases, leading to skin that is not as elastic and will not recede with limit fluid in the evenings to offset nocturia, but limiting fluids may weight loss, so bags develop readily under the eyes.9 Also, skin lead to nocturnal dehydration. Sodium and chloride levels remain wounds heal more slowly because of decreased cell regeneration. constant, but potassium decreases. Many changes occur in the GI tract, such as decreased enzyme se- OLDER ADULT cretion, gastric irritation, decreased nutrient and drug absorption, decreased hydrochloric acid secretion, decreased peristalsis and Nutritional status of the older adult is receiving increased scrutiny elimination, and decreased sphincter muscle tone, making nutrition by health care professionals because of the impact poor nutrition a primary concern. Older adults need decreased and nutrient-dense Copyright © 2002 F.A. Davis Company 92 NUTRITIONAL-METABOLIC PATTERN calories. Adequate intake of vitamins and trace elements along with 8. Frequent exacerbations of chronic health problems such as adequate protein, fat, carbohydrates, bulk, and electrolytes is impor- pneumonia or urinary tract infections tant. The decreased intake of milk and fresh fruits, commonly found 9. Cognitive decline (decline in mental processing) as evidenced by in older populations, is a source of concern because of the continu- problems with responding appropriately to environmental stim- ing need for calcium, fiber, and vitamin intake.29 uli, demonstrates difficulty in reasoning, decision making, judg- Integumentary changes result in skin that is drier and thinner, ment, memory, and concentration, and decreased perception and skin lesions or discolorations and scaliness (keratosis) may ap- 10. Decreased social skills or social withdrawal—noticeable de- pear. Wrinkling occurs in areas commonly exposed to the sun, such crease from usual past behavior in attempts to form or partic- as the face and hands. Fatty layers lost in the trunk, face, and ex- ipate in cooperative and independent relationships (e.g., de- tremities leads to the appearance of increased joint size throughout creased verbal communication with staff, family, and friends) the body. The skin becomes less elastic with aging and may lose wa- 11. Decreased participation in activities of daily living that the ter to the air in low-humidity situations, leading to skin chapping. older person once enjoyed The older adult has difficulty tolerating temperature extremes. 12. Self-care deficit—no longer looks after or takes charge of phys- Body temperature may increase because of a decrease in the size, ical cleanliness or appearance number, and function of the sweat glands. Decreased fat cells and 13. Difficulty performing simple self-care tasks changes in peripheral blood flow make older adults more sensi- 14. Neglects home environment and/or financial responsibilities tive to cooler conditions. Older adults may wear sweaters or ad- 15. Apathy as evidenced by lack of observable feeling or emotion ditional layers of clothing when the external temperature feels in terms of normal activities of daily living and environment comfortable or warm to younger individuals. Melanocyte de- 16. Altered mood state—expresses feelings of sadness or being low creases lead to pale skin color and gray hair. Hair loss is common. in spirit Older women, with imbalances in androgen-estrogen hormones, 17. Expresses loss of interest in pleasurable outlets such as food, may have noticeable increases in facial and chin hairs. Aging sex, work, friends, family, hobbies, or entertainment changes to the skin can result in tactile changes, and therefore, the 18. Verbalizes desire for death ability to perceive temperature, touch, pain, and pressure is di- minished.25 Decreased tactile ability may lead to thermal, chemi- RELATED FACTORS30 cal, and mechanical injury that is not readily detected by the older adult. 1. Depression 2. Apathy 3. Fatigue APPLICABLE NURSING DIAGNOSES RELATED CLINICAL CONCERNS Adult Failure to Thrive 1. Any terminal diagnosis, e.g., cancer, AIDS, or multiple sclerosis 2. Chronic clinical depression DEFINITION 3. Any chronic disease 4. Cerebrovascular accident or

paralytic conditions A progressive functional deterioration of a physical and cognitive nature; the individual’s ability to live with multisystem diseases, cope with ensuing problems, and manage his or her care is re- markably diminished.30 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? NANDA TAXONOMY: DOMAIN 13—GROWTH/ DEVELOPMENT; CLASS 1—GROWTH Imbalanced Nutrition, Less Than Body Requirements This diagnosis could be a NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING companion diagnosis because Imbalanced ASSISTANCE Nutrition, Less Than Body Requirements would be a defining characteristic in Adult NOC: DOMAIN I—FUNCTIONAL HEALTH; Failure to Thrive. Adult Failure to Thrive CLASS B—GROWTH AND DEVELOPMENT appears in chronic conditions and involves much more than just altered nutrition. DEFINING CHARACTERISTICS30 Impaired Swallowing This diagnosis relates only to the swallowing process and is not 1. Anorexia—does not eat meals when offered inclusive enough to cover all the problem 2. States does not have an appetite, not hungry, or “I don’t want areas of Adult Failure to Thrive. to eat” 3. Inadequate nutritional intake—eating less than body require- ments 4. Consumes minimal to none of food at most meals (i.e., con- EXPECTED OUTCOME sumes less than 75 percent of normal requirements at each or most meals) Will gain X pounds of weight by [date]. 5. Weight loss (decreased body mass from base line weight— 5 percent unintentional weight loss in 1 month, 10 percent un- TARGET DATES intentional weight loss in 6 months) 6. Physical decline (decline in body function) Adult Failure to Thrive will require long-term intervention. Target 7. Evidence of fatigue, dehydration, and incontinence of bowel dates should initially be stated in terms of weeks. After improve- and bladder ment is shown, target dates can be expressed in terms of months. Copyright © 2002 F.A. Davis Company ADULT FAILURE TO THRIVE 93 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: A recent study31 demonstrates a relationship between Adult Failure to Thrive and Helicobac- ter pylori infection. The clinical presentation of the infection was characterized by the lack of symp- toms typically associated with gastric diseases, such as nausea, vomiting, dyspepsia, and abdominal pain. Instead, the patient exhibited signs of aversion to food, decline in mental functions, and the in- ability to perform activities of daily living (ADL). ACTIONS/INTERVENTIONS RATIONALES • Refer to Nutrition, Imbalanced, Less Than Body Requirements Basic methods and procedures that improve nutrition and appetite. for basic nursing actions or interventions. • Monitor for: Allows early detection of complications and assists in monitoring � Swallowing deficit effectiveness of therapy. � Occult blood in stools � Dehydration; replace with IV fluids as ordered � Electrolytes • Offer soft, regular diet with nutritional liquid supplement. Easily chewed and digested food. • Document intake and output. • Do not force oral feedings. Risk for aspiration pneumonia. • Administer drugs as ordered. Assess for side effects: Approved drugs by the Food and Drug Administration (FDA) for � Antibiotics infections in peptic ulcer disease.32 � Hydrogen-ion proton inhibitors • Administer nutritional liquids via gastric enteral tube as ordered. (See Additional Information for Imbalanced Nutrition, Less Than Body Requirements, page 166.) • Collaborate with the multidisciplinary team. Child Health This diagnosis would not be used with infants or children. Women’s Health Nursing actions for this diagnosis are the same as those for Adult Health. Psychiatric Health NOTE: For clients with severe or life-threatening compromised physiologic status, refer to Adult Health for interventions. When the client is psychologically unstable, refer to the following plan of care. Monitor client for suicidal ideation. If this is determined to be an issue, appropriate interventions should be implemented utilizing the Risk for Violence diagnosis. ACTIONS/INTERVENTIONS RATIONALES • Spend [number of] minutes with the client [number of] times per shift to establish relationship with the client. • Discuss with the client and client’s support system the client’s food preferences. (Note here special foods and adaptations needed.) • Provide the client with opportunity to make food choices. Opportunities to increase personal control improve self-esteem and Initially these should be limited so the client will not be have a positive impact on mood.33–35 overwhelmed with decisions. Note client choices here. • Provide the client with necessary sensory and eating aids. (Note here those needed for this client. This could include eyeglasses, dentures, and special utensils.) • Provide quiet, calm milieu at mealtimes. Clients with mood disorders may have difficulty with concentration.36 • Provide the client with adequate time to eat. Clients with mood disorders may experience psychomotor retardation that can expand the time it takes them to eat.36 • Provide foods that meet the client’s preferences that are of high Meeting basic health needs improves stamina.36 nutritional value and require little energy to eat. (continued) Copyright © 2002 F.A. Davis Company 94 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Sit with the client during meals and provide positive verbal Fatigue may limit the client’s physical energy.36 reinforcement. Note here client-specific reinforcers. • When the client’s mental status improves, spend [number of] This demonstrates acceptance of the client and facilitates problem minutes each shift with the client discussing issues and solving.34 concerns. Note here those issues important for the client to discuss. • When the client’s mental status improves, engage the client in Decreases sense of loneliness and isolation, increases [number of] therapeutic groups per day. Note here the groups self-understanding, increases social support, and facilitates the the client will attend. development of relationship and coping skills.34,35 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review the older adult’s medication list for possible Adverse reactions to medications such as antidepressants, beta medication-induced failure to thrive. blockers, neuroleptics, anticholinergics, benzodiazepines, potent diuretic combination drugs, and anticonvulsants and polypharmacy (more than 4–6 prescription drugs) can lead to cognition changes, anorexia, dehydration, or electrolyte problems and result in failure to thrive.37 • Monitor weight loss pattern according to care setting policy or In older adults, a percentage weight loss over a 6- to 12-month client contact opportunities. Maintain weight information in an time period is associated with increased risk of disease, disability, easily retrievable place to allow quick access and ease in and mortality.38 comparison of weights. • Review nutritional pattern with the client and/or caregiver to Poor nutrition can lead to adverse clinical outcomes for older determine whether adequate nutritional support is present. adults.38 • Arrange for psychological supports for the older client, such as The therapies listed promote self-worth, decrease stress, focus on validation therapy, reminiscing, life review, or cognitive therapy. the client’s strengths, and provide the opportunity for resolution of prior unfinished conflicts.39 • Refer the older client for evaluation of depression. Depression is frequently underdiagnosed in the older adult and is often associated with unintentional weight loss in the older population.38 • Review the social support system available to the client. Social isolation is considered a significant feature in depression, malnutrition, and decreased function in older adults.40 • Encourage the client to participate in a regular program of Exercise can prevent further loss of muscle mass often found with exercise. failure to thrive and improve strength and energy.27 Home Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the client to identify times of day when fatigue is Allows the client some control of activities. worse, and space activities around the times when he or she is less fatigued. • Assist the client in obtaining durable medical equipment for the Makes self-care activities less tiring. home (e.g., bedside commode and shower chair) until the fatigue improves. • Encourage the client to rest before scheduled activities. May help avoid exacerbation of the fatigue. • Encourage the client to participate in walking activity as Fatigue seems to show improvement with walking programs. tolerated. • Encourage the client to eat small, frequent meals that are high Allows maximum nutrition without discomfort from large meals. in calories and protein. • Weigh the client twice weekly. Ensures that weight loss is not excessive. • Teach the client and caregivers the importance of avoiding Caffeine is a diuretic and exacerbates dehydration. caffeinated beverages. • Offer small frequent sips of water or preferred beverage. Prevents development or exacerbation of dehydration. • Interspace fluids with high–fluid content foods (e.g., popsicles, Prevents development or exacerbation of dehydration. gelatin, and ice cream). (continued) Copyright © 2002 F.A. Davis Company ADULT FAILURE TO THRIVE 95 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client and caregivers in obtaining necessary supplies Helps reduce frustration and embarrassment. for the management of incontinence (e.g., pads and diapers). • For clients who are confused, reorient to place and time as Prevents episodes of agitation related to confusion. needed. • Teach the client and caregivers to give medications as ordered Prevents exacerbation of existing problems. (e.g., antidepressants). Copyright © 2002 F.A. Davis Company 96 NUTRITIONAL-METABOLIC PATTERN Adult Failure to Thrive FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient gained X pounds of weight? Yes No Record data, e.g., has gained 10 lb Reassess using initial assessment factors. in past 4 weeks. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. NOTE: Because this is a long-term diagnosis, may want to use CONTINUE until defining characteristics are resolved. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., weight same as 4 weeks ago—93 lb. Record Did evaluation show another CONTINUE and change target problem had arisen? Yes date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company ASPIRATION, RISK FOR 97 Aspiration, Risk for 6. Medication administration 7. Wired jaws DEFINITION 8. Increased gastric residual 9. Incompetent lower esophageal sphincter The state in which an individual is at risk for entry of GI secretions, 10. Impaired swallowing oropharyngeal secretions, or solids or fluids into tracheobronchial 11. GI tubes passages.30 12. Facial, oral, or neck surgery or trauma 13. Depressed cough and gag reflexes NANDA TAXONOMY: DOMAIN 11—SAFETY/ 14. Decreased GI motility PROTECTION; CLASS 2—PHYSICAL INJURY 15. Delayed gastric emptying NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; CLASS K—RESPIRATORY MANAGEMENT RELATED FACTORS30 NOC: DOMAIN II—PHYSIOLOGIC HEALTH; The risk factors also serve as the related factors for this nursing CLASS E—CARDIOPULMONARY diagnosis. DEFINING CHARACTERISTICS (RISK FACTORS)30 RELATED CLINICAL CONCERNS 1. Increased intragastric pressure 1. Closed head injury 2. Tube feedings 2. Any diagnosis with presenting symptoms of nausea and vomiting 3. Situations hindering elevation of upper body 3. Bulimia 4. Reduced level of consciousness 4. Any diagnosis requiring use of a nasogastric tube 5. Presence of tracheostomy or endotracheal tube 5. Spinal cord injury HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Swallowing Swallowing means that when themselves, or because messages to the brain are food or fluids are present in the mouth, the brain absent, decreased, or impaired. signals both the epiglottis and the true vocal cords to Ineffective Airway Clearance In Ineffective move together to close off the trachea so that the Airway Clearance, the patient is unable to food and fluids can pass into the esophagus and thus effectively clear secretions from the respiratory into the stomach. Impaired Swallowing implies that tract because of some of the same related factors there is a mechanical or physiologic obstruction as are found with Risk for Aspiration. However, in between the oropharynx and the esophagus that Ineffective Airway Clearance, the defining prevents food or fluids from passing into the characteristics (abnormal breath sounds, cough, esophagus. In Risk for Aspiration there may or may change in rate or depth of respirations, etc.) are not be an obstruction between the oropharynx and associated directly with respiratory function, the esophagus. The major pathophysiologic whereas the defining characteristics of Risk for dysfunction that occurs in Risk for Aspiration is the Aspiration are directly or indirectly related to the inability of the epiglottis and true vocal cords to oropharyngeal mechanisms that protect the move to close off the trachea. This inability to close tracheobronchial passages from the entrance of off the trachea may occur because of foreign substances. pathophysiologic changes in the structures EXPECTED OUTCOME TARGET DATES Will implement plan to offset Risk for Aspiration by [date]. Aspiration is life threatening. Initial target dates should be stated in hours. After the number of risk factors has been reduced, the tar- get dates can be moved to 2- to 4-day intervals. Copyright © 2002 F.A. Davis Company 98 NUTRITIONAL-METABOLIC PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Have suction equipment available.

Would be required for emergency relief of aspiration. • Sit the patient up or elevate head of bed, especially during Decreases risk of reflux from stomach thus decreasing risk of meals, if not contraindicated. If contraindicated, place the aspiration. Placing the patient on right side facilitates food passage patient on right side. into the pylorus. • Feed slowly and cut food into small bites. Instruct the patient to All these measures are designed to reduce the risk of aspiration. chew thoroughly. Observe gag and cough reflexes. Monitor for Decreased sensation may allow pocketing of food in mouth. food and secretion accumulation in mouth. Sit with the patient during mealtime if cognitive functioning indicates a need for close observation. • Teach the patient to be cognizant of closing off trachea before Reduces risk of aspiration and promotes compliance by involving attempting to swallow: the patient in his or her plan of care. � Have the patient clear his or her throat by coughing and expectorating. If the patient is unable to expectorate, suction the secretions. � Have the patient inhale as food is put in the mouth. � Have the patient then perform a Valsalva maneuver as he or she is swallowing. � Have the patient cough, swallow again, and exhale deeply. � Start with soft, nonacidic, noncrumbly foods rather than Liquids are more difficult to control. liquids. � Discuss with the patient the purpose for any alterations in care necessitated by this diagnosis, e.g., upright position; small, frequent meals; soft foods. • Offer small, frequent feedings at least 6 times a day rather than Liquids are more easily aspirated than soft food. Smaller and more 3 large meals per day. Offer soft foods rather than a full liquid frequent feedings reduce risk of aspiration while maintaining diet. nutritional status. • Delay fluids associated with meals for at least 30 min after each Decreases the likelihood of coughing, gagging, and choking. meal. • Have the patient cough and clear secretions prior to offering any food or fluid. • Teach the patient to limit conversation while either eating or drinking. • Provide calm, relaxed atmosphere during mealtime, and assist the patient with relaxation exercises as needed. • Teach the patient and family the Heimlich maneuver and have Would assist in episodes of choking and would allow the patient them return-demonstrate at least daily for 3 days before discharge. and family to feel comfortable with level of expertise before going home. • Teach the patient and family suctioning technique as needed, including appropriate ordering of supplies. • Refer the patient and family to appropriate resources. Provides long-term teaching and support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine best position for the patient as determined by Natural upper airway patency is facilitated by upright position. underlying risk factors, e.g., head of bed elevated 30 degrees Turning to right side decreases likelihood of drainage into trachea with the infant propped on right side after feeding. rather than esophagus in the event of choking. • Check bilateral breath sounds every 30 min or with any change In the event of aspiration, increased gurgling and rales with in respiratory status. correlated respiratory difficulty (from mild to severe) will be noted. • Measure amount of residual, immediately before feeding, in Monitors the speed of digestion and indicates the patient’s ability nasogastric tube and report any excess beyond 10 to 20 percent to tolerate the feeding. of volume or as specified. • Note and record the presence of any facial trauma or surgery Monitoring for these risk factors assists in preventing unexpected or of face, head, or neck with associated drainage. undetected aspiration. (continued) Copyright © 2002 F.A. Davis Company ASPIRATION, RISK FOR 99 (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor for risk factors that would promote aspiration, e.g., An increased stimulation or sensitivity to the gag reflex increases increased intracranial pressure, Reye’s syndrome, nausea the likelihood of choking and possible aspiration. associated with medications, cerebral palsy, or neurologic damage. • Assist the patient and family to identify factors that help prevent aspiration, e.g., avoiding self-stimulation of gag reflex, avoiding deep oral or pharyngeal suctioning, and chewing food thoroughly. • Provide opportunities for the patient and family to ask Allows an opportunity to decrease anxiety, provides time for questions or ventilate regarding risk for aspiration by teaching, and allows individualized home care planning. scheduling at least 30 min twice a day at [times] for discussing concerns. • Teach the family and patient (if old enough) age-appropriate Basic safety measures for dangers of aspiration. cardiopulmonary resuscitation (CPR), first aid, and Heimlich maneuver. Women’s Health NOTE: The following actions pertain to the newborn infant in the presence of meconium in amniotic fluid. ACTIONS/INTERVENTIONS RATIONALES • Alert obstetrician and pediatrician of the presence of meconium Presence of meconium alerts health care providers to possible in amniotic fluid. complications. • Assemble equipment and be prepared for resuscitation of the Basic emergency preparedness. newborn at the time of delivery. • Be prepared to suction the infant’s nasopharynx and oropharynx while head of the infant is still on the perineum. • Immediately evaluate and record the respiratory status of the newborn infant. • Assist pediatrician in viewing the vocal cords of the infant (have various sizes of pediatric laryngoscopes available). If meconium is present, be prepared to insert endotracheal tube for further suctioning. • Continue to evaluate and record the infant’s respiratory status. There is no designated time frame for observation; however, the nurse needs to continue to evaluate the infant for at least 12–24 h for respiratory distress and the complications of pulmonary interstitial emphysema, pneumomediastinum, pneumothorax, persistent pulmonary hypertension, central nervous system (CNS) dysfunction, and renal failure. These infants should be placed in a level 2 or 3 nursery. • Reassure the parents by keeping them informed of actions. Reduces anxiety. • Allow opportunities for the parents to verbalize fears and ask Reduces anxiety and provides teaching opportunity. questions. Psychiatric Health NOTE: Clients receiving electroconvulsive therapy (ECT) are at risk for this diagnosis. ACTIONS/INTERVENTIONS RATIONALES • Remain with the client who has had ECT until gag reflex and Basic safety measures until the client can demonstrate control. swallowing have returned to normal. Monitor gag reflex and swallowing every 30 min until return to normal. • Place the client who has had ECT on right side until reactive. Lessens the probability of aspiration through the influence of gravity on stomach contents. • Clients in four-point restraint should be placed on right side or Lessens probability of aspiration due to difficulty in swallowing stomach. Elevate the client’s head to eat, and remove restraints tablets or pills that might cause gagging. one at a time to facilitate eating. Request that oral medications be changed to liquid forms. • Observe clients receiving antipsychotic agents for possible One side effect of these medications is suppression of the cough suppression of cough reflex. reflex. Loss of this reflex promotes the likelihood of aspiration. Copyright © 2002 F.A. Davis Company 100 NUTRITIONAL-METABOLIC PATTERN Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Older adults may develop a decreased gag reflex. To reduce the Establishes baseline data to use for comparison after the procedure risk of aspiration: is completed. � Monitor gag reflex before any procedures involving anesthesia such as bronchoscopy, esophagogastroduodenoscopy (EGD), or general surgery. • Monitor gag reflex post procedure before giving fluids or solids. Ensuring return of gag reflex decreases risk of aspiration once oral intake is resumed. Home Health The nursing actions for home health care of this diagnosis are the same as the actions enumerated in the Adult Health portion. Copyright © 2002 F.A. Davis Company ASPIRATION, RISK FOR 101 Aspiration, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient implemented a plan to reduce the Risk for Aspiration? Yes No Record data, e.g., accurately return- Reassess using initial assessment factors. demonstrates trach care, is eating slower, is sitting up for at least 1 hour after meals. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., weight still has problems with swallowing, Did evaluation show another still lying down immediately problem had arisen? Yes after each meal. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 102 NUTRITIONAL-METABOLIC PATTERN Body Temperature, Imbalanced, Risk for 3. Medications causing vasoconstriction or vasodilation 4. Inappropriate clothing for environmental temperature DEFINITION 5. Inactivity or vigorous activity 6. Extremes of weight The state in which the individual is at risk for failure to maintain 7. Extremes of age body temperature within normal range.30 8. Dehydration 9. Sedation NANDA TAXONOMY: DOMAIN 11—SAFETY/ 10. Exposure to cold or cool or warm or hot environments PROTECTION; CLASS 6—THERMOREGULATION RELATED FACTORS30 NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; CLASS M—THERMOREGULATION The risk factors also serve as the related factors for this nursing di- agnosis. NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS I—METABOLIC REGULATION RELATED CLINICAL CONCERNS DEFINING CHARACTERISTICS (RISK FACTORS)30 1. Any infectious process 2. Hyperthyroidism/hypothyroidism 1. Altered metabolic rate 3. Any surgical procedure 2. Illness or trauma affecting temperature regulation 4. Head injuries HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Risk for Imbalanced Body Temperature needs to be which a person maintains a temperature higher differentiated from Hypothermia, Hyperthermia, than normal. This means that the body is probably and Ineffective Thermoregulation. producing heat normally but is unable to dissipate Hypothermia Hypothermia is the condition in which the heat normally. Both heat production and heat a person maintains a temperature lower than normal dissipation are potentially nonfunctional in Risk for for him or her. This means that the body is probably Imbalanced Body Temperature. As with dissipating heat normally but is unable to produce Hypothermia, a temperature measurement shows heat normally. In Risk for Imbalanced Body an abnormal measurement. Temperature both heat production and heat Ineffective Thermoregulation Ineffective dissipation are potentially nonfunctional. In Thermoregulation means that a person’s Hypothermia, a lower than normal body temperature temperature fluctuates between being too high and can be measured. In Risk for Imbalanced Body too low. There is nothing wrong, generally, with Temperature, temperature measurement may not heat production or heat dissipation; however, the show an abnormality until the condition has changed thermoregulatory systems in the hypothalamus or to Hyperthermia or Hypothermia. the thyroid are dysfunctional. Again, a temperature Hyperthermia Hyperthermia is the condition in measurement shows an abnormality. EXPECTED OUTCOME TARGET DATES Will have no alteration in body temperature by [date]. Initial target dates would be stated in hours. After stabilization, tar- get dates could be extended to 2 to 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to Risk for Imbalanced Body Detects overproduction or underproduction of heat. Temperature at least every 2 h on [odd/even] hour. (Refer to Risk Factors.) • Monitor temperature for at least every 2 h on [odd/even] hour. • Note pattern of temperature for last 48 h. Assists in ascertaining any trends. Typical viral-bacterial differentiation may be possible to detect on temperature curves. (continued) Copyright © 2002 F.A. Davis Company BODY TEMPERATURE, IMBALANCED, RISK FOR 103 (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor skin and mucous membrane integrity every 2 h on Allows early detection of impaired tissue integrity, which can lead [odd/even] hour. to infection. • Maintain fluid and electrolyte balance. Monitor intake and Adequate hydration assists in maintaining normal body core output every hour. temperature. • If temperature is above or below 98.6F (or parameters defined by physician), take appropriate measures to bring temperature back to normal range. Refer to nursing actions for Hypothermia, page 145, or Hyperthermia, page 140. • Follow up with cultures for identification of causative organisms Identification of organism allows determination of most if infection is present. appropriate antibiotic therapy. • Maintain consistent room temperature. Prevents overheating or overcooling due to environment. • Teach the patient to wear appropriate clothing and modify Regulates constant metabolism and provides warmth. routines to prevent alterations in body temperature: � Wear close-knit undergarments in winter to prevent heat loss. � Wear hat and gloves in cold weather because heat is lost from head and hands. � Wear wool in preference to synthetic fibers, because wool provides better insulation. � Wear socks or

stockings in bed at night. � Wear light, loose, but protecting clothing in hot weather. � Wear hat in hot weather to protect head. � Use sheet blankets rather than regular sheets. � Try to stay indoors on windy days. � Try to work outdoors in early morning and to work for limited periods of time. � Have frequent, small meals every 3 to 4 h and warm liquids every 2 h on the [odd/even] hour. • Avoid sedatives and tranquilizers that depress cerebral function Risk factors for this diagnosis. and circulation. • Assist the patient to learn to assess biorhythms. Generally early Helps determine peak and trough of temperature variations. morning is the period of lowest body metabolic activity; add extra clothes until food and physical movement stimulate increased cellular metabolism and circulation. • Alternate physical and sedentary activity every 2 h on Assists in maintaining consistency in metabolic functioning. [odd/even] hour. • Teach patients to use heating pads and electric blankets in a safe Basic safety measure. manner. • Refer to nursing diagnoses Hypothermia or Hyperthermia for interventions related to these situations once the alteration has occurred. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor temperature at least every hour. The young infant and child may lack mature thermoregulatory capacity. Temperatures either too high (102F or above) or too low (below 97F) may bring about spiraling metabolic demise for acid- base status. Seizures and shock may follow. • If temperature is less than 97F rectally (or parameters defined Young infants and children may not be able to initiate by physician), take appropriate measures for maintaining compensatory regulation of temperature, especially in premature temperature: and altered CNS/immune conditions. These basic measures must � Infants: Radiant warmer or isolette be taken to safeguard a return to homeostatic condition. � Older Child: Thermoblanket � Administer medications as ordered. • Be cautious to not overdose in a 24-h period. Abide by Using caution in dosage calculation and abiding by appropriate recommended dosage schedule per 8 h or pediatric medication guidelines minimize inadvertent overdosing and subsequent recommendations. untoward effects of medication. • If temperature is above 101F, take appropriate measures to Young infants and children may have febrile seizures due to bring temperature back to normal range (or at least 98–100F): immature thermoregulatory mechanisms and must be appropriately � Administer Tylenol, antibiotics, or other medications as safeguarded against further sequelae. ordered. (continued) Copyright © 2002 F.A. Davis Company 104 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Monitor and document related symptoms with specific regard for potential febrile seizures. � Monitor for the development of febrile seizures, and check for history of febrile seizures. � If the infant or child has reduced threshold for seizures Anticipatory planning promotes optimal resuscitation efforts. during times of fever, be prepared to treat seizures with anticonvulsants, maintain airway, and provide for safety from injury. � Provide appropriate teaching to the child and parents related Self-care empowers and fosters long-term confidence as well as to hyperthermia and hypothermia, e.g., temperature reduces anxiety. measurement, wearing of proper clothing, use of Tylenol instead of aspirin, consuming adequate amounts of food and fluid, and use of tepid baths. � Be cautious and do not overtax the infant or child with Increased metabolic demands in the presence of an already taxed congestive heart failure or pulmonary problems by allowing cardiopulmonary status can become severe, resulting in a temperature elevation to develop. life-threatening conditions if left untreated. � Avoid use of aspirin and aspirin products. Standards of care per the American Academy of Pediatrics to decrease the potential for Reye’s syndrome. � Avoid use of tympanic membranous thermometer in infants Studies indicate that tympanic thermometers are inaccurate in of 6 mo or less. infants, especially those younger than 3 mo of age. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying lifestyle adjustments necessary So-called hot flashes related to changes in the body’s core to maintain body temperature within normal range during temperature can be somewhat controlled in women by estrogen various life phases, e.g., perimenopause or menopause. replacement therapy; however, as hormone levels fluctuate with the aging process, some hot flashes will occur. These can be helped by adjusting the environment, e.g., room temperature, amount of clothing, or temperature of fluids consumed. • Maintain house at a consistent temperature level of 70–72F. • Keep bedroom cooler at night and layer blankets or covers that can be discarded or added as necessary. • Have the patient drink cool fluids, e.g., iced tea or cold soda. • Have the patient wear clothing that is layered so that jackets, etc. can be discarded or added as necessary. • In collaboration with physician, assist the patient in Individuals have unique, different requirements as to the amount understanding role of estrogen and the amount of estrogen of estrogen necessary to maintain appropriate hormone levels. It is replacement necessary during perimenopause and menopause. of prime importance that each patient can recognize what her body’s needs are and communicate this information to the health care provider.5 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Observe clients receiving neuroleptic drugs for signs and Neuroleptic drugs may decrease the ability to sweat and therefore symptoms of hyperthermia. Teach clients these symptoms and make it difficult for the client to reduce body temperature.41,42 caution them to decrease their activities in the warmest part of the day and to maintain adequate hydration, especially if they are receiving lithium carbonate with these drugs. • Observe clients receiving antipsychotics and antidepressants for Antipsychotics and antidepressants can cause a loss of loss of thermoregulation. The elderly client, especially, should thermoregulation. The client’s learned avoidance behavior can be be monitored for this side effect. Provide the client with extra altered and consciousness can be clouded as a result of clothing and blankets to maintain comfort. Protect this client medications.41,42 from contact with uncontrolled hot objects such as space heaters and radiators. Heating pads and electric blankets can be used with supervision. (continued) Copyright © 2002 F.A. Davis Company BODY TEMPERATURE, IMBALANCED, RISK FOR 105 (continued) ACTIONS/INTERVENTIONS RATIONALES • Do not provide electric heating devices to the client who is on Basic safety measure. suicide precautions or who has alterations in thought processes. • Notify physician if the client receiving antipsychotic agents has Antipsychotics, especially chlorpromazine and thioridazine, can an elevation in temperature or flu-like symptoms. cause agranulocytosis. This risk is greatest 3–8 wk after therapy has begun.41,42 Clients who have experienced this side effect in the past should not receive the drug again because a repeat episode is highly possible. • Review the client’s complete blood count (CBC) before drug is Basic monitoring for agranulocytosis. started, and report any abnormalities on subsequent CBCs to the physician. • Clients receiving phenothiazines should be monitored for hot, These medications can produce hyperthermia, which can be fatal. dry skin, CNS depression, and rectal temperature elevations This hyperthermia is due to a peripheral autonomic effect.41,42 (can be as high as 108F). Monitor the client’s temperature 3 times a day while awake at [times]. Notify physician of alterations. • Monitor clients receiving tricyclic antidepressants (TCAs) and The side effect of a hyperpyretic crisis can be produced in clients the monoamine oxidase inhibitors (MAOIs) for alterations in receiving these medications.41,42 temperature 3 times a day while awake [note times here]. Notify physician of any alterations. Gerontic Health Nursing actions are the same as those given in the Adult Health section. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach measures to decrease or eliminate Risk for Imbalanced Appropriate environmental temperature regulation provides Body Temperature: support for physiologic thermoregulation. � Wearing appropriate clothing. � Taking appropriate care of underlying disease. � Avoiding exposure to extremes of environmental temperature. � Maintaining temperature within norms for age, sex, and height. � Ensuring appropriate use of medications. � Ensuring proper hydration. � Ensuring appropriate shelter. • Assist the client and family to identify lifestyle changes that may Support is often helpful when individuals and families are be required: considering lifestyle alterations. � Learn survival techniques if client works or plays outdoors. � Measure temperature in a manner appropriate for the developmental age of the person. � Maintain ideal weight. � Avoid substance abuse. • Involve the client and family in planning, implementing, and Involvement of the client and family provides opportunity to promoting reduction or elimination of the Risk for Imbalanced increase motivation and enhance self-care. Body Temperature by establishing family conferences to set mutual goals and to improve communication. • Consult with appropriate assistive resources as indicated. Cost-effective and appropriate use of available resources. Copyright © 2002 F.A. Davis Company 106 NUTRITIONAL-METABOLIC PATTERN Body Temperature, Imbalanced, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient have a temperature either above or below the normal range? Yes No Reassess using initial assessment factors. Record data, e.g., oral temperature measurement has remained between 97 and 99°F for past 5 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Is diagnosis validated? Did evaluation show another Yes No problem had developed? Record data, e.g., oral temperature has ranged from 97 to 101°F for past 2 days, has lost 10 lb, is still Yes No exhibiting signs and symptoms of dehydration. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company BREASTFEEDING, EFFECTIVE 107 Breastfeeding, Effective 5. Mother able to position infant at breast to promote a successful latch-on response. DEFINITION 6. Signs and/or symptoms of oxytocin release (let-down or milk ejection reflex). The state in which a mother-infant dyad-family exhibits adequate 7. Adequate infant elimination patterns for age. proficiency and satisfaction with the breastfeeding process.30 8. Eagerness of infant to nurse. 9. Maternal verbalization of satisfaction with the breastfeeding NANDA TAXONOMY: DOMAIN 7—ROLE process. RELATIONSHIPS; CLASS 3—ROLE PERFORMANCE NIC: DOMAIN 5—FAMILY; CLASS W— RELATED FACTORS30 CHILDBEARING CARE 1. Infant gestational age more than 34 weeks NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 2. Support sources CLASS K—NUTRITION 3. Normal infant oral structure 4. Maternal confidence 5. Basic breastfeeding knowledge DEFINING CHARACTERISTICS30 6. Normal breast structure 1. Mother-infant communication patterns (infant cues, maternal interpretation, and response) are effective. RELATED CLINICAL CONCERNS 2. Regular and sustained suckling and swallowing at the breast. Because this is a wellness diagnosis, there are no related clinical 3. Appropriate infant weight patterns for age. concerns. 4. Infant is content after feeding. HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Breastfeeding Effective Breastfeeding is than the degree of attachment with the infant. a wellness diagnosis. It signifies a successful Although Effective Breastfeeding contributes to the experience for both the mother and the baby. If attachment of the infant to the mother and the there is a problem with breastfeeding, then the mother to the infant, the supplying of the infant appropriate diagnosis is Ineffective Breastfeeding. with nutrition by breastfeeding or by formula These two diagnoses could be considered to be at feeding should be differentiated from attachment opposite ends of a continuum. processes, which are addressed in Impaired Impaired Parenting Effective Breastfeeding focuses Parenting, Risk for or Actual, and Parental Role on the nutrition and growth of the infant, rather Conflict. EXPECTED OUTCOME TARGET DATES The infant will have: Although it usually takes 2 to 3 weeks for the mother and infant to establish a mutual pattern of feeding, an initial target date of 4 days 1. Adequate weight gain and return to birth weight by 3 weeks of age, should be set to ensure an effective beginning to the breastfeeding 2. Six or more wet diapers in 24 hours, and process. 3. At least 2 stools every 24 hours NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this diagnosis, Women’s Health nursing actions serve as the generic actions. This diagnosis would probably not arise on an adult health unit. Child Health It is doubtful this diagnosis would arise on a child health care unit. Please see nursing actions under Women’s Health. Women’s Health NOTE: If the diagnosis of Effective Breastfeeding has been made, the most appropriate nursing action is continued support for the diagnosis. Successful lactation can be established in any woman who does not have structural anomalies of the milk ducts and who exhibits a desire to breastfeed. Adoptive moth- ers

can breastfeed as well as birthmothers. The following actions serve to facilitate the development of Effective Breastfeeding. Copyright © 2002 F.A. Davis Company 108 NUTRITIONAL-METABOLIC PATTERN ACTIONS/INTERVENTIONS RATIONALES • Review the mother’s knowledge base regarding breastfeeding To determine the basis for assistance and teaching. Avoids prior to the initial breastfeeding of the infant. unessential repetition for the mother. • Demonstrate and assist the mother and significant other with Successful lactation depends on understanding the basic how-to’s correct breastfeeding techniques, e.g., positioning and latch-on. and correct techniques for the actual feeding act. • Teach the mother and significant other basic information related to successful breastfeeding, e.g., milk supply, diet, rest, breast care, breast engorgement, infant hunger cues, and parameters of a healthy infant. • Assess the mother’s breasts for graspable nipples, surgical scars, Provides the assessment base for diagnosing of potential problems skin integrity, and abnormalities prior to the initial as well as the base for developing strategies for success. breastfeeding of the infant. • Assess the infant for ability to breastfeed prior to breastfeeding, e.g., state of awareness or physical abnormalities. • Place the infant to breast within the first hour after birth unless It is important to work with the infant’s sleep-wake cycle in contraindicated (mother or infant instability) and on cue establishing breastfeeding after birth. If the infant can successfully afterward. suckle immediately after birth, a successful and encouraging pattern is usually established for both the mother and the infant. • To initiate or maintain lactation when the mother is unable to This assists in establishing and maintaining the milk supply. It breastfeed the infant, encourage the mother to express breast also allows the mother to provide emotional support as well as milk either manually or by using a breast pump at least every 3 h. nutritional support to the infant who cannot breastfeed because of prematurity or illness. • Observe the infant at breast, noting behavior, position, latch-on, and sucking technique with the initial breastfeeding and then as necessary. Document these observations in the mother’s and infant’s charts. • Encourage the mother and significant other to identify support The majority of women who are successfully breastfeeding when systems to assist her with meeting her physical and psychosocial leaving the hospital quit after 3 wk at home. Support systems are needs at home. a critical component in the maintenance of successful lactation.43 • Encourage the mother to drink at least 2000 mL a day, or 8 oz every hour, of fluids. • To provide sufficient amounts of calcium, protein, and calories, Breastfeeding mothers should increase their caloric intake to encourage the mother to eat a wide variety of foods from the 2000 to 2500 cal/day in order to maintain successful lactation. Food Pyramid. • Encourage the mother to breastfeed at least every 2–3 h for a Newborns need frequent feeding to satisfy their hunger and to minimum of 10 min per side to establish milk supply, then establish their feeding patterns. It is important that the mother regulate feeding according to infant’s demands. understand the infant’s suckling will determine the supply and demand of breast milk. • Monitor the infant’s output for number of wet diapers. Helps determine intake and nutritional status of infant. Document the number of diapers and the color of urine. (Remember, there should be at least 6 in a 24-h period.) • Weigh the infant at least every third day and record. • Assist the mother in planning a day’s activities when Helps the new mother establish a schedule that is beneficial for breastfeeding to ensure that the mother gets sufficient rest. both the mother and infant. • Encourage advanced planning for the working mother if she intends to continue to breastfeed after returning to work. • Involve the father or significant other in breastfeeding by The breastfeeding mother requires a lot of support and encouraging the “provider-protector” role. encouragement. Fathers can supply this by providing her with time for rest and assistance with infant care. For example, the father can bring the infant to the mother at night rather than the mother having to get up each time for the feeding. Fathers can intervene with family and friends to provide nursing mothers privacy and quiet. Psychiatric Health This diagnosis will not be applicable in a mental health setting. Gerontic Health This diagnosis is not applicable in gerontic health. Home Health The Home Health nursing actions for this diagnosis are the same as those for Women’s Health. Copyright © 2002 F.A. Davis Company BREASTFEEDING, EFFECTIVE 109 Breastfeeding, Effective FLOWCHART EVALUATION: EXPECTED OUTCOME Has the infant demonstrated adequate weight gain, and has the infant returned to his or her birth weight? Has the infant had 6 or more wet diapers each 24 h? Has the infant had at least 2 stools every 24 h? Yes No Record data, e.g., weight on 11/1, Reassess using initial assessment factors. 6 lb 8 oz, weight on 11/3, 6 lb 11 oz, birth weight, 6 lb 10 oz. Has averaged 8 wet diapers per 24 h. Has averaged 2 stools each 24 h. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has gained only 2 oz, is 8 oz under birth Did evaluation show another weight, average 4 wet diapers/ problem had arisen? Yes 24 h and 1 stool/24 h. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 110 NUTRITIONAL-METABOLIC PATTERN Breastfeeding, Ineffective 10. Infant exhibiting fussiness and crying within the first hour after breastfeeding DEFINITION 11. Actual or perceived inadequate milk supply 12. No observable signs of oxytocin release The state in which a mother, infant, or child experiences dissatis- 13. Insufficient opportunity for sucking at the breast faction or difficulty with the breastfeeding process.30 RELATED FACTORS30 NANDA TAXONOMY: DOMAIN 7—ROLE RELATIONSHIPS; CLASS 3—ROLE PERFORMANCE 1. Nonsupportive partner or family 2. Previous breast surgery NIC: DOMAIN 5—FAMILY; CLASS W— 3. Infant receiving supplemental feedings with artificial nipple CHILDBEARING CARE 4. Prematurity 5. Previous history of breastfeeding failure NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 6. Poor infant sucking reflex CLASS K—NUTRITION 7. Maternal breast anomaly 8. Maternal anxiety or ambivalence DEFINING CHARACTERISTICS30 9. Interruption in breastfeeding 10. Infant anomaly 1. Unsatisfactory breastfeeding process 11. Knowledge deficit 2. Nonsustained sucking at the breast 3. Resisting latching on RELATED CLINICAL CONCERNS 4. Unresponsiveness to other comfort measures 5. Persistence of sore nipples beyond the first week of breastfeeding 1. Any diseases of the breast 6. Observable signs of inadequate infant intake 2. Cleft lip; cleft palate 7. Insufficient emptying of each breast per feeding 3. Failure to thrive 8. Inability of infant to attach onto maternal breast correctly 4. Prematurity 9. Infant arching and crying at the breast 5. Child abuse HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Breastfeeding should be differentiated environment that promotes optimum growth and from the patient’s concern over whether she wants development of another human being. Adjustment to breastfeed or not. Although a mother who does to parenting, in general, is a normal maturation not want to breastfeed will more than likely be process following the birth of a child. ineffective in her breastfeeding attempts, ineffective Delayed Growth and Development: Self-Care breastfeeding can be related to problems other than Skills This diagnosis is defined according to a just an unwillingness to breastfeed. Other diagnoses demonstrated deviation from age group norms for that need to be differentiated include: self-care. Inadequate caretaking would be defined Anxiety Anxiety is defined as a vague, uneasy according to specific behavior and attitudes of the feeling, the source of which is often nonspecific or individual mother or infant. unknown to the individual. If an expression of Ineffective Individual Coping This diagnosis is perceived threat to self-concept, health status, defined as the inability of the individual to deal socioeconomic status, role functioning, or with situations that require coping or adaptation to interaction patterns is made, this would constitute meet life’s demands and roles. All the changes the diagnosis of Anxiety. secondary to the birth of a new baby could result Impaired Parenting Impaired Parenting is defined in this diagnosis. as the inability of the nurturing figures to create an EXPECTED OUTCOME TARGET DATES Infant will require no supplemental feedings by [date]. Because Ineffective Breastfeeding can be physically detrimental to the infant as well as emotionally detrimental to the mother, an ini- tial target date of 3 days would be best. Copyright © 2002 F.A. Davis Company BREASTFEEDING, INEFFECTIVE 111 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this nursing diagnosis, the Women’s Health nursing actions serve as the generic nursing actions. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to the infant’s ability to suck: Assessment of the infant’s ability to suck assists in meeting goals for � Structural abnormalities, e.g., cleft lip or palate effective breastfeeding. � Altered level of consciousness, seizures, or CNS damage � Mechanical barriers to sucking, e.g., endotracheal tube or ventilator � Pain or underlying altered comfort or medication � Prematurity with diminished sucking ability • Determine the effect the altered or impaired breastfeeding The maternal-infant responses provide the essential database in has on the mother and infant by providing at least one determining how serious the breastfeeding issues are. This 30-min period per day for talking with the mother. Monitor information dictates how to approach the problem and promote maternal feelings expressed, maternal-infant behaviors realistic follow-up. observed, and excessive crying or unrelenting fussiness in the infant. • To the degree possible, provide emotional support for the infant Provides temporary substitutions for breastfeeding that promote in instances of temporary inability to breastfeed, e.g., gavage trust and sense of security for the infant. Also, bonding with the feedings with appropriate cuddling. Include the parents in care. mother is still possible. Allow the infant to suck on pacifier if possible. • Coordinate the parents’ visitation with the infant to best facilitate successful breastfeeding in such areas as rest, natural hunger cycles, and comfort of all involved. • Assist with plan to manage impaired breastfeeding to best provide Maintain the mother’s confidence in breastfeeding. Supporting her support to all involved, e.g., breast-pumping for period of time choice for alternative feeding demonstrates valuing of her beliefs. with support for this effort until normal breastfeeding can be resumed. Breast milk may be frozen or even given in gavage feeding. Support the mother’s choice for whatever alternatives are chosen. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Ascertain the mother’s desire to breastfeed the infant through Provides intervention base for nursing actions. Allows planning of careful interviewing and reviewing of the mother’s knowledge support, teaching, and evaluation of motives and desires to of breastfeeding. breastfeed. • List the advantages and disadvantages of breastfeeding for the Assists the mother to make an informed decision about mother. breastfeeding. • Obtain a breastfeeding and bottle-feeding history from the mother, e.g., did she breastfeed before, and if so, was it successful or unsuccessful? • Allow for uninterrupted breastfeeding periods. Providing the mother and infant with uninterrupted breastfeeding times allows them to become acquainted with each other and allows time for learning different breastfeeding techniques. • Collaborate with physician, lactation consultant, perinatal Assists the mother who has strong desire to breastfeed to be clinical nurse specialist, etc. to determine ways to make successful. abnormal breast structure amenable for breastfeeding. • Observe the mother with the infant during breastfeeding. Provides basic information and visible support to assist with Explain and demonstrate methods to increase infant sucking successful breastfeeding. reflex. Demonstrate to the mother various positions for breastfeeding and how to alternate positions with each feeding to prevent nipple soreness, e.g., sitting up, lying down, using football hold, holding the baby “tummy to tummy,” using pillows for the mother’s comfort, or using pillows for supporting the baby. (continued) Copyright © 2002 F.A. Davis Company 112 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Ascertain the mother’s need for privacy during breastfeeding. Promotes the mother’s comfort with the physical act of breastfeeding. • Monitor for poor or dysfunctional sucking by checking: Proper positioning facilitates satisfaction with breastfeeding for � Position the mother is using to hold the baby both the mother

and baby. � Baby’s mouth position on areola and nipple � Position of the baby’s head, e.g., inappropriate hyperextension • Ascertain the mother’s support for breastfeeding from others, Support from others is essential in attaining successful breastfeeding. e.g., husband or significant other, patient’s mother, obstetrician, pediatrician, and nurses on postpartum unit. • Discuss the infant’s needs and frequency of feedings. Provides basic information and visible support to assist with successful breastfeeding. • Assist the mother in planning a day’s activities when Provides information necessary for the mother to plan the basics of breastfeeding, ensuring that the mother gets plenty of rest. her self-care. • Teach the patient: � The proper diet for the breastfeeding mother, listing important food groups and necessary calories to adequately maintain milk production � The idea of advanced planning for the working mother who plans to breastfeed � That it takes time to establish breastfeeding (usually a month) � The use of various hand pumps, battery-operated pumps, and electric pumps � How to hand-express breast milk � How to properly store expressed breast milk • Schedule specific times for consultation and support for the mother. Plan at least 30 min per shift (while awake) for talking with the mother. • If the baby is separated from the mother, such as in neonatal intensive care unit (NICU), involve the baby’s nurses in planning with the mother routines and times for breastfeeding the infant. • Refer the mother to breastfeeding support groups. Provides basic information and visible support to assist with successful breastfeeding. • For the mother who has had a cesarean section, place a pillow Assists in keeping pressure off the incision line while breastfeeding. over the abdomen before putting infant to breast. • Assist the mother of a premature baby to pump breast routinely to initiate milk production. • Demonstrate proper storage and transportation of breast milk Basic teaching to ensure safe nutrition for infant. for the premature baby. • Assist the mother who has to wean a premature baby from tube Provides needed support during this process. feedings to breastfeeding by: � Teaching the mother to place the infant at the breast several times a day and during tube feeding � Encouraging the mother to hold, cuddle, and interact with the infant during tube feedings � Allowing the mother and infant privacy to begin interaction with breastfeeding � Being available to assist with the infant during breastfeeding interaction � Reassuring the mother that it might take several attempts before the baby begins to breastfeed • Give breastfeeding mothers copies of educational materials. Provides a readily available information source. • If breastfeeding is not possible because of an infant physical Allows the mother the option of breastfeeding in the event that the deformity, teach the mother how to pump breasts and how to deformity can be surgically corrected. feed the infant breast milk in bottles with special nipples. • Encourage maternal attachment behavior. Assists the mother in adjustment to parenting and effective caretaking of the infant. Psychiatric Health Refer to Women’s Health nursing actions for interventions related to this diagnosis. Gerontic Health This diagnosis is not appropriate for gerontic health. Copyright © 2002 F.A. Davis Company BREASTFEEDING, INEFFECTIVE 113 Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach measures to promote effective breastfeeding, e.g., quiet Knowledge and support increase the likelihood of a positive environment, adequate nutrition and hydration, appropriate outcome. technique, and family support. • Assist the client and family in identifying risk factors pertinent Identification of and early interventions in high-risk situations to the situation: provide the opportunity to prevent problems. � Premature infant � Infant anomaly � Maternal breast dysfunction � Infection � Previous breast surgery � Supplemental bottle feedings � Nonsupportive family � Lack of knowledge � Anxiety • Consult with or refer to appropriate resources as indicated. Appropriate and cost-effective use of available resources. Copyright © 2002 F.A. Davis Company 114 NUTRITIONAL-METABOLIC PATTERN Breastfeeding, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the mother. Is the infant requiring supplemental feedings? Yes No Reassess using initial assessment factors. Record data, e.g., has not required supplemental feedings for past 10 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Is diagnosis validated? Did evaluation show a new Yes No problem had developed? Record data, e.g., infant still not satisfied at end of each breast feeding, requires 2 to 3 oz supplemental Yes No feeding to avoid fussiness and weight loss. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company BREASTFEEDING, INTERRUPTED 115 Breastfeeding, Interrupted 3. Maternal desire to maintain lactation and provide (or eventually provide) her breast milk for her infant’s nutritional needs DEFINITION 4. Separation of the mother and infant A break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding.30 RELATED FACTORS30 1. Contraindications to breastfeeding (e.g., drugs or true breast NANDA TAXONOMY: DOMAIN 7—ROLE milk jaundice) RELATIONSHIPS; CLASS 3—ROLE PERFORMANCE 2. Maternal employment 3. Maternal or infant illness NIC: DOMAIN 5—FAMILY; CLASS W— 4. Need to abruptly wean infant CHILDBEARING CARE 5. Prematurity NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS K—NUTRITION RELATED CLINICAL CONCERNS DEFINING CHARACTERISTICS30 1. Any condition requiring emergency admission of the mother to hospital 1. Infant not receiving nourishment at the breast for some or all of 2. Any condition requiring emergency admission of the infant to feedings hospital 2. Lack of knowledge regarding expression and storage of breast 3. Prematurity milk 4. Postpartum depression HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Breastfeeding With Ineffective Ineffective Infant Feeding Pattern In this Breastfeeding, there is expressed dissatisfaction or diagnosis, there is a defined problem with the problems with breastfeeding. With Interrupted infant’s ability to suck, swallow, and breathe. Breastfeeding, there is no expressed dissatisfaction Breastfeeding for this infant has not ever been or major problems; however, Breastfeeding has successful. With Interrupted Breastfeeding, the temporarily ceased as a result of factors beyond infant has no problems with sucking or the mother’s control. swallowing, and the stoppage of breastfeeding can be overcome by storing breast milk and feeding the infant via a bottle. EXPECTED OUTCOME TARGET DATES Infant will demonstrate no weight loss secondary to adaptations for Because this interruption might occur as a result of an emergency, Interrupted Breastfeeding by [date]. initial evaluation should occur within 24 hours after the initial di- agnosis. Thereafter, target dates can be moved to every 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Arrange care activities to facilitate the mother’s breastfeeding of the Supports continued successful breastfeeding, attachment, and infant according to feeding schedule of the mother-infant dyad. bonding. • Encourage continuation of breastfeeding: � Arrange special visitation privileges for the infant and infant’s caregiver during the time of the mother’s hospitalization. � Provide privacy for the family. � Collaborate with diet therapist regarding mother’s nutritional needs during this time. � Provide breast pump for the mother and assist with breast Helps relieve engorgement. Milk can be stored and used to feed pumping as needed every 3–4 h. the infant. • Collaborate with perinatal clinical nurse specialist and/or Provides needed consultation for nurse and her patient. lactation consultant regarding maintenance of breastfeeding. Copyright © 2002 F.A. Davis Company 116 NUTRITIONAL-METABOLIC PATTERN Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for infant’s ability to suck. Encourage sucking on a Provides basic data critical to success. In times of non-breastfeeding, regular basis, especially if gavage feedings are a part of the it is beneficial to encourage sucking to reinforce the feeding time as therapeutic regimen. pleasurable and to enhance digestion, unless contraindicated by a surgical or medical condition, e.g., cleft repair of lip or palate, prolonged NPO (nothing by mouth) status with concerns for air swallowing. • Provide support for the mother-infant dyad to facilitate Feedback may provide essential valuing during times of stress. breastfeeding satisfaction. • Monitor infant cues suggesting satisfaction: The fact that the infant’s satisfaction and input are valued provides � Weight gain appropriate for status a critical component in the entire process of breastfeeding. � Ability to sleep at intervals Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Provide appropriate information on why breastfeeding needs to Assists breastfeeding families in establishing and maintaining be interrupted. Be specific about length of time, i.e., days, breastfeeding capabilities when it is inadvisable or impossible to weeks, or months, and offer options for maintaining breast milk put the baby to the breast for feeding. until able to resume breastfeeding.43–45 • Describe routine for pumping, expressing, and storing of breast milk during emergency period. • Contact lactation consultant and/or perinatal nurse who can assist with plan of nursing care and with maintenance of breast milk during mother’s illness, e.g., emergency surgery, medical regimen (medications) that contradict breastfeeding, or injury requiring hospitalization of mother.46,47 • Provide the mother with appropriate information about breast pumps and how to obtain one (rent or buy) to aid in expression of breast milk, i.e., semiautomatic breast pump, automatic breast pump, battery-operated breast pump, or manual breast pump. • Demonstrate and have the mother return-demonstrate proper assembly and use of breast pump. • Assist the mother in learning manual expression of breast milk47: � Good handwashing technique before expressing milk � Correct positioning of hand and fingers so as not to damage breast tissue � Sterile wide-mouth funnel and bottle for storage of breast milk • Discuss options for maintaining breastfeeding with the mother who is returning to work. Provide assistance to help the mother establish feeding schedule with work schedule, e.g., breastfeed a.m. and p.m., pumping at noon, etc.45–47 • Provide resources, e.g., printed materials or consultant, to assist the mother when negotiating with employer for time and place to pump or breastfeed during working hours.47 • Assist the mother and family to arrange schedule to bring the infant to her during working hours. • Encourage the mother and significant other to verbalize their frustrations and concerns about establishing and maintaining lactation when the infant is ill or premature.48–51 • Refer to lactation consultant or clinical nurse specialist who Provides basic information that assists in promoting effective can support the parents and assist the nurse in developing a breastfeeding. program of breastfeeding or supplementing of the infant with the mother’s breast milk.52 Copyright © 2002 F.A. Davis Company BREASTFEEDING, INTERRUPTED 117 Psychiatric Health NOTE: This diagnosis will not, in all likelihood, be applicable in a mental health setting. Should a mother be admitted with a mental health–related diagnosis, the physician would probably suggest changing the infant to bottle-feedings. Should the physician agree that breastfeeding could continue, the adult health actions would be applicable for the mental health client. Gerontic Health This diagnosis is not appropriate for gerontic health. Home Health NOTE: If home care is needed because of either mother or infant illness or disability, the nurse will need to address the underlying problem in order to promote Effective Breastfeeding. It is not likely that home health care would be initiated if the only diagnosis was Ineffective Breastfeeding; however, there are lactation consultants whose entire practice is home health. This practice has been specifically designed to assist with maintenance of successful lactation. ACTIONS/INTERVENTIONS RATIONALES • Support the mother, infant, and family dynamics for successful Encouragement and support increase the potential for positive breastfeeding. outcomes. • Recognize cultural variations in feeding practices when assessing Feeding patterns vary according to cultural norms. effectiveness of breastfeeding. • Provide additional education or referrals as requested or as Community-based support is ongoing; early intervention as the situation changes. situation changes increases the potential for continued effectiveness. Copyright © 2002 F.A. Davis Company 118 NUTRITIONAL-METABOLIC PATTERN Breastfeeding, Interrupted FLOWCHART EVALUATION: EXPECTED OUTCOME Has the infant lost weight since onset of interrupted breastfeeding? No Yes Record data, e.g., has gained Reassess using initial assessment factors. 2 oz since mother admitted to hospital. Grandmother states infant eating and sleeping well. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has lost 2 oz since

mother admitted to Did evaluation show another hospital. Grandmother states problem had arisen? Yes infant does not like formula. She believes now that mother can pump breasts, infant will do better. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company DENTITION, IMPAIRED 119 Dentition, Impaired 12. Tooth fractures 13. Missing teeth or incomplete absence DEFINITION 14. Erosion of enamel 15. Asymmetric facial expression Disruption in tooth development, eruption patterns, or structural integrity of individual teeth.30 RELATED FACTORS30 NANDA TAXONOMY: DOMAIN 11—SAFETY/ 1. Ineffective oral hygiene PROTECTION; CLASS 2—PHYSICAL INJURY 2. Sensitivity to heat or cold 3. Barriers to self-care NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 4. Access or economic barriers to professional care CLASS F—SELF-CARE FACILITATION 5. Nutritional deficits 6. Dietary habits NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 7. Genetic predisposition CLASS L—TISSUE INTEGRITY 8. Selected prescription medications 9. Premature loss of primary teeth DEFINING CHARACTERISTICS30 10. Excessive intake of fluoride 11. Chronic vomiting 1. Excessive plaque 12. Chronic use of tobacco, coffee, tea, or red wine 2. Crown or root caries 13. Lack of knowledge regarding dental health 3. Halitosis 14. Excessive use of abrasive cleaning agents 4. Tooth enamel discoloration 15. Bruxism 5. Toothache 6. Loose teeth RELATED CLINICAL CONCERNS 7. Excessive calculus 8. Incomplete eruption for age (may be primary or permanent 1. Dental surgery teeth) 2. Elderly wearing dentures 9. Malocclusion or tooth misalignment 3. Facial trauma 10. Premature loss of primary teeth 4. Anorexia or bulimia 11. Worn down or abraded teeth 5. Malnutrition HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Imbalanced Nutrition, Less Than Body diagnosis of Imbalanced Nutrition, Less Than Requirements Impaired Dentition might be a Body Requirements. primary factor in the development of Imbalanced Adult Failure to Thrive Again, Impaired Dentition Nutrition, Less Than Body Requirements. might contribute to the development of Adult Impaired Dentition is a very specific diagnosis Failure to Thrive. This means Impaired Dentition related only to the teeth and would require would need to be resolved before the broader intervention before working on the broader definition of Adult Failure to Thrive. EXPECTED OUTCOME TARGET DATES Will return-demonstrate complete oral hygiene by [date]. One week would be an appropriate time period to check initial progress toward resolving this problem area. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage well-balanced diet including fiber. Provides essential nutrition. • Encourage or assist the patient with oral hygiene after meals Cleans and lubricates the mouth. Encourages the patient to eat and at bedtime. and drink. • If Impaired Dentition predisposes to Imbalanced Nutrition, Less Than Body Requirements, refer to that nursing diagnosis. (continued) Copyright © 2002 F.A. Davis Company 120 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • If Impaired Dentition predisposes to Imbalanced Nutrition, More Than Body Requirements, refer to that nursing diagnosis. • If Impaired Dentition is related to chronic vomiting, refer to the nursing diagnosis for Nausea. • If Impaired Dentition is related to chronic use of tobacco, Encourages health promotion and decreases factors related to coffee, tea, or red wine, encourage the patient to stop this usage. Impaired Dentition. • Consult with dietitian to provide soft, nonmechanical diet. Makes food easier to chew, thereby encouraging essential nutrition. • Consult with social worker to help the patient find affordable access to professional dental care. • Teach the patient about dental health. Assists in preventive maintenance and good oral health. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributing factors to include, but not Consideration of all possible etiologies best helps identify treatment limited to, organic, genetic, familial, medical, prenatal, or modalities. neonatal factors; prematurity; jaundice; significant injuries or exposures; and nutritional possibilities. • Determine whether there are coexistent congenital anomalies. Primary deficits may exist in isolation or in combination with other deficits. • Identify current dental hygiene for the client (expectations Preventive maintenance knowledge offers a baseline for hygiene according to age norms; e.g., 6 months—gentle cleansing of routines for age. gums with soft cotton cloth). • Monitor the mouth fully for status of gums and teeth, if present, Actual observation assists in accuracy of diagnosis and treatment. type and location, condition of enamel, and alignment or malocclusion. • Determine pattern of tooth appearance and correlation to norms Expected norms assist in identification of deviations. for primary and secondary teeth. • Determine patterns of tooth loss according to norms for primary Expected norms assist in identification of deviations. and secondary teeth. • Make appropriate recommendations for maintenance, Appropriate referral to specialists offers maximum potential for prophylactic, and restorative care of the client’s teeth and gums. long-term maintenance of dentition health. • Offer appropriate education for safeguarding permanent teeth Anticipatory planning assists in dentition health maintenance. for the client and family, to include indications for mouth guards during contact sports, ways to minimize risk of injury, and importance of seeking immediate attention of dentist in event of accidental loss of tooth. • Ascertain client and parental knowledge regarding medications, Validation of actual knowledge or care issues affords optimum dietary factors, special orthodontia, or other related likelihood of adherence to regimen for the individual client. maintenance issues. • Provide information for local support groups when applicable, Support groups foster shared experience with validation of peer e.g., Dental Association. input. • Determine resources for continued maintenance, including Resources help provide appropriate care as situation permits. financial, as determined on an individual basis. Women’s Health Nursing interventions for Maternal Health are the same as those for Adult Health. NOTE: It is important to practice good dental health during pregnancy. A pregnant woman needs ap- proximately 1.2 g of calcium and phosphorus daily during pregnancy to help maintain bony stores. Psychiatric Health The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Determine the client and/or caregiver’s ability to perform oral Physical aging changes associated with chronic disease such as hygiene measures. arthritis may limit the ability to perform oral care.53 (continued) Copyright © 2002 F.A. Davis Company DENTITION, IMPAIRED 121 (continued) ACTIONS/INTERVENTIONS RATIONALES • Review and/or teach the client strategies for good oral hygiene Many older adults have not been taught how to adequately clean as necessary, i.e., daily flossing, brushing after meals, and using their teeth by brushing and flossing.53 correct equipment (soft-bristled tooth brush).54 • Refer the client to an occupational therapist, if needed, for Older adults may experience problems with gripping toothbrushes assistive equipment and techniques to enhance oral hygiene or using dental floss, and thus adequate oral care is inhibited.55 practices.55 • Advocate for clients to ensure access to dental services. Many older adults are reluctant to use dental services because of cost concerns.54 • If dentures are present, monitor for appropriate fit, bedtime There is continuous resorption of ridges beneath dentures over removal of dentures, and presence of food trapping under time, causing a slow change in how well dentures fit. Failure to dentures after meals. remove dentures at bedtime may result in oral trauma or breathing problems if the dentures are loose. Food trapping can lead to mucosal inflammation from organisms trapped under dentures.53 Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client in obtaining dentures when appropriate. Assists the client to increase nutritional intake and improve appearance. • Assist the client in replacing poorly fitting dentures when Decreases multiple problems created by poorly fitting dentures. necessary. Older clients will require correction of denture fit every few years. • Teach the client proper oral care: Prevents exacerbation of existing conditions. � Brushing teeth after each meal � Vigorous mouth rinsing � Flossing at least once daily • Teach the client appropriate dietary modifications: � Reducing refined carbohydrates � Reducing between-meal snacks • Assist the client in obtaining oral care products as necessary. Encourages proper oral hygiene. • Educate clients about signs and symptoms of tooth decay and Encourages self-care and prevention. periodontal disease and when to seek medical or dental care. Copyright © 2002 F.A. Davis Company 122 NUTRITIONAL-METABOLIC PATTERN Dentition, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate complete oral hygiene? Yes No Record data, e.g., correctly brushes Reassess using initial assessment factors. and flosses teeth. Brushes tongue and gum. Uses mouthwash correctly. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., brushes teeth for less than 20 sec; does not Did evaluation show another floss; copious use of mouthwash problem had arisen? Yes to mask halitosis. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company FLUID VOLUME, DEFICIENT, RISK FOR AND ACTUAL 123 Fluid Volume, Deficient, Risk for and Actual 8. Excessive losses through normal routes, for example, diar- rhea DEFINITIONS30 B. Deficient Fluid Volume 1. Decreased urine output Risk for Deficient Fluid Volume The state in which an individ- 2. Increased urine concentration ual is at risk of experiencing vascular, cellular, or intracellular de- 3. Sudden weight loss (except in third spacing) hydration. 4. Decreased venous filling 5. Increased body temperature Deficient Fluid Volume The state in which an individual experi- 6. Decreased pulse volume or pressure ences decreased intravascular, interstitial, and/or intracellular 7. Changes in mental status fluid. This refers to dehydration, water loss alone without change 8. Increased hematocrit in sodium. 9. Decreased skin and/or tongue turgor 10. Dry skin or mucous membranes NANDA TAXONOMY: DOMAIN 2—NUTRITION; 11. Thirst CLASS 5—HYDRATION 12. Increased pulse rate 13. Decreased blood pressure NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; CLASS N—TISSUE PERFUSION MANAGEMENT RELATED FACTORS30 NOC: DOMAIN II—PHYSIOLOGIC HEALTH; A. Risk for Deficient Fluid Volume CLASS G—FLUID AND ELECTROLYTES The risk factors also serve as the related factors for this diagnosis. DEFINING CHARACTERISTICS30 B. Deficient Fluid Volume 1. Active fluid volume loss A. Risk for Deficient Fluid Volume 2. Failure of regulatory mechanisms 1. Factors influencing fluid needs, for example, hypermeta- bolic state RELATED CLINICAL CONCERNS 2. Medications, for example, diuretics 3. Loss of fluid through abnormal routes, for example, in- 1. Addison’s disease (adrenal insufficiency or crisis) dwelling tubes 2. Hemorrhage 4. Knowledge deficiency related to fluid volume 3. Burns 5. Extremes of age 4. AIDS 6. Deviations affecting access to or intake or absorption of 5. Crohn’s disease fluids, for example, physical immobility 6. Vomiting and diarrhea 7. Extremes of weight 7. Ulcerative colitis HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Oral Mucous Membrane and Imbalanced regulatory function and there is significant loss of Nutrition, Less than Body Requirements The client fluid and electrolytes. may not be able to ingest food or fluid because of Self-Care Deficit or Impaired Parenting In the primary problems in the mouth, or the client just infant or young child, the problem may primarily may not be ingesting enough food from which the be a Self-Care Deficit or Impaired Parenting. The body can absorb fluids. infant or young child is not able to obtain the fluid Bowel Incontinence, Diarrhea, or Urinary he or she wants and must depend on others. If the Incontinence These diagnoses may be causing an parents are unable to recognize or meet these extreme loss of fluid before it can be absorbed and needs, then the infant or young child may have a used by the body. Risk for or Actual Deficient Fluid Volume. Even in Impaired Skin Integrity This diagnosis could be an adult, the primary nursing diagnosis may be the primary problem. For example, the patient who Self-Care Deficit. Again, if the adult is unable to has been burned has grossly impaired skin obtain the fluid he or she requires because of integrity. The skin is supposed to regulate the some pathophysiologic problem, then he or she amount of fluid lost from it. If there is relatively may have a Risk for or Actual Deficient Fluid little intact skin, the skin is unable to perform its Volume. EXPECTED OUTCOME TARGET DATES Intake and output will balance within 200 mL by [date]. Normally, intake and output will approximately balance only every 72 hours; thus, an appropriate target date would be 3 days. Copyright © 2002 F.A. Davis Company 124 NUTRITIONAL-METABOLIC PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Measure

and record total intake and output every shift: Determines fluid loss and need for replacement. � Check intake and output hourly. � Observe and document color and consistency of all urine, stools, and vomitus. � Check urine specific gravity every 4 h at [state times here]. • Take vital signs every 2 h on [odd/even] hour and include Permits monitoring of cardiovascular response to illness state and apical pulse. replacement therapy. • Monitor intravenous fluids. (See Additional Information for Monitoring of fluid replacement and prevention of fluid overload. Imbalanced Nutrition, Less Than Body Requirements, page 157). • Monitor: � Skin turgor at least every 4 h at [state times here] while awake � Electrolytes, blood urea nitrogen, hematocrit, and Essential monitoring for fluid and electrolyte imbalance. hemoglobin (Collaborate with physician regarding frequency of laboratory tests.) � Central venous pressure every hour (if appropriate) � Mental status and behavior at least every 2 h on the [odd/even] hour � For signs and symptoms of shock at least every 4 h at [state times here], e.g., weakness, diaphoresis, hypotension, tachycardia, or tachypnea • Weigh daily at [state time here]. Teach the patient to weigh at Monitoring for fluid replacement. Allows consistent comparison same time each day in same-weight clothing. of weight. • Force fluids to a minimum of 2000 mL daily: � Ascertain the patient’s fluid likes and dislikes [list here]. � Offer small amount of fluid (4–5 oz) at least every hour while awake and at every awakening during night. � Offer fluids at temperature that is most acceptable to the patient, i.e., warm or cool. � Interspace fluids with high-fluid-content foods, e.g., popsicles, gelatin, pudding, ice cream, or watermelon. Note the patient’s preferences here. • Administer medications as ordered, e.g., antidiarrheal or antiemetics. Monitor medication effects. • Assist the patient to eat and drink as necessary. Provide positive Prevents dehydration and easily replaces fluid loss without verbal support for the patient’s consuming fluid. resorting to IVs. Frequent fluids improve hydration; variation in fluids is helpful to encourage the patient to increase intake. • Administer or assist with oral hygiene after each meal and Cleans and lubricates the mouth. Encourages the patient to eat before bedtime. and drink. • Turn and properly position the patient at least every 2 h on [odd/even] hour. • Encourage the patient to alter position frequently. • Provide active and passive range of motion (ROM) every 4 h at Prevents stasis of fluids in any one part of body. Assists in [state times here] while awake. circulation of fluid. • Schedule at least 1-h rest periods for patient at least 4 times a Prevents overexertion and extra strain on circulatory system. day at [times]. • If temperature elevation develops: � Maintain cool room temperature. � Offer cool, clear liquids. � Administer ordered antipyretics. � Give tepid sponge bath. � Remove heavy and excess clothing and bed covers. Assists in reducing fluid loss due to perspiration, etc. • If gastric tube is present: � Use only normal saline for irrigation. � Monitor amount of oral intake of water and ice chips. Avoid Avoids altering of electrolyte balance, which, in turn, may alter fluid if at all possible. Offer commercial electrolyte replenishment volume balance. solutions if permitted, e.g., Gatorade or 10K. (continued) Copyright © 2002 F.A. Davis Company FLUID VOLUME, DEFICIENT, RISK FOR AND ACTUAL 125 (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach the patient, prior to discharge, to increase fluid intake at home during: � Elevated temperature episodes � Periods when infection and elevated temperatures are present � Periods of exercise � Hot weather • Measures to ensure adequate hydration: Support the patient’s self-care by pointing out measures he or she � Need to drink fluids before feeling of thirst is experienced can use to control fluid imbalance. Adequate intake and early � Recognizing signs and symptoms of dehydration such as dry intervention will prevent undesirable outcomes. skin, dry lips, excessive sweating, dry tongue, and decreased skin turgor � How to measure, record, and evaluate intake and output • Refer to other health care professionals as necessary. Provides support and fosters cost-effective collaboration through use of readily available resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Measure and record total intake every shift: A 24-h fluid assessment is meaningful for diagnosing deficits and � Check intake and output hourly (may require weighing also provides a basis for replacement needs. diapers or insertion of a Foley catheter [infants may require use of a 5 or 8 feeding tube if size 10 Foley is too large]). � Check urine specific gravity every 2 h on [odd/even] hour or Specific gravity is a good indicator of degree of hydration. every voiding or as otherwise ordered. • Force fluids to a minimum appropriate for size (will be closely Prompt replacement and maintenance of appropriate fluids related to electrolyte needs and cardiac, respiratory, and renal prevents further circulatory or systemic problems. Specific status): attention is also required with respect to sodium, potassium, and � Infants: 70–100 mL/kg in 24 h caloric intake. Infants are subject to fluid volume depletion � Toddler: 55–70 mL/kg in 24 h because of their relatively greater surface area, higher metabolic � School-age child: 20–50 mL/kg in 24 h rate, and immature renal function.56 • Weigh the patient daily at same time of day, on same scale, and Accuracy of weight cannot be overstressed. The weight often in same clothing (infants without diaper). serves as a major indicator of the effectiveness of the treatment regimen. Iatrogenic problems are more likely to occur with inaccuracies. • Assist in individualizing oral intake to best suit the patient’s When options exist, honoring them facilitates better compliance needs and preferences. Include parents in designing this plan. with goals and helps the patient and family to feel valued. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to identify lifestyle factors that could be Provides basis for treatment of symptoms and basis for teaching contributing to symptoms of nausea and vomiting during and support strategies. early pregnancy: � Identify the patient’s support system. � Monitor the patient’s feelings (positive or negative) about pregnancy. � Evaluate social, economic, and cultural conditions. � Involve significant others in discussion and problem-solving activities regarding physiologic changes of pregnancy that are affecting work habits and interpersonal relationships (e.g., nausea and vomiting). • Teach the patient measures that can help alleviate pathophysiologic changes of pregnancy. • In collaboration with dietitian: � Obtain dietary history. � Assist the patient in planning diet that will provide adequate nutrition for her and her fetus’s needs. (continued) Copyright © 2002 F.A. Davis Company 126 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach methods of coping with gastric upset, nausea, and Provides information, education, and support for self-care during vomiting: pregnancy. � Eat bland, low-fat foods (no fried foods or spicy foods). � Increase carbohydrate intake. � Eat small amounts of food every 2 h (avoid empty stomach). � Eat dry crackers or toast before getting up in the morning. � Take vitamins and iron with night meal before going to bed (vitamin B, 50 mg, can be taken twice a day but never on an empty stomach). � Drink high-protein liquids (e.g., soups or eggnog).5 • Monitor the patient for: Provides basis for therapeutic intervention if necessary as well as � Variances in appetite support of that patient, which can decrease fear and feelings of � Vomiting between 12–16 wk of pregnancy helplessness. � Weight loss � Intractable nausea and vomiting • Collaborate with physician regarding monitoring for: Provides support and information to increase self-awareness and � Electrolyte imbalance: hemoconcentration, ketosis with self-care. ketonuria, hyponatremia, hypokalemia � Dehydration (Note: “During pregnancy, gastric acid secretion normally is reduced because of increased estrogen stimulation. This places the women at risk for alkalosis rather than the acidosis that usually occurs in an advanced stage of dehydration.”57) � Hydration (approximately 3000 mL/24 h) and providing vitamin supplements � Restriction of oral intake and providing parental administration of fluids and vitamins (Note: “Vitamin B6 has been found effective and safe for use in nausea and vomiting of pregnancy.”5) • Allow expression of feelings and encourage verbalization of fears and questions by scheduling at least 30 min with the patient at least once per shift. • Provide the patient and family with diet information for the Provides information that allows for successful lactation and breastfeeding mother to prevent dehydration: healthy recovery from childbirth. � Increase daily fluid intake. � Drink at least 2000 mL of fluid daily. � Extra fluid can be taken just before each breastfeeding (e.g., water, fruit juices, decaffeinated tea, or milk). � Eat well-balanced meals to include the basic food groups. • Teach the parents fluid intake needs of the newborn. The newborn should be taking in approximately 420 mL soon after birth and building to 1200 mL at the end of 3 mo. • Monitor the newborn for fluid deficit, and teach the parents to Provides information and support for healthy growth and monitor via the following factors: development of the newborn. � “Fussy baby,” especially immediately after feeding � Constipation (remember, breastfed babies have fewer stools than formula-fed babies) � Weight loss or slow weight gain • Evaluate the baby, mother, and nursing routine: � Is the baby getting empty calories (e.g., a lot of water between feedings)? � Monitor the baby for nipple confusion from switching the baby from breast to bottle and vice versa many times. � Count number of diapers per day (should have 6–8 really wet diapers per day). � Monitor the infant for intolerance to the mother’s milk or bottle formula. • Monitor the baby for illness or lactose intolerances. • Monitor how often the mother is nursing the infant (infrequent nursing can cause slow weight gain). Copyright © 2002 F.A. Davis Company FLUID VOLUME, DEFICIENT, RISK FOR AND ACTUAL 127 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • If the client is confused or is unable to interpret signs of thirst, Medications and/or clouded consciousness may affect the client’s place on intake and output measurement, and record this ability to recognize need for fluids. information every shift. • Evaluate potential for fluid deficit resulting from medication or Estimated daily requirement for adults is 1500–3000 mL/day.58 medication interaction, e.g., lithium and diuretics. If this presents a risk, place the client on intake and output measurement every shift. • Evaluate mental status every shift at [times]. Basic monitoring to determine the client’s ability to independently take fluids. • If the client’s values and beliefs influence intake: � Alter environment as necessary to facilitate fluid intake, and note alterations here, e.g., if the client thinks fluids from cafeteria are poisonous, have the client assist in making drink on unit. � Provide positive attention to the client at additional times to avoid not drinking as a way of obtaining negative attention. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to drink at least 8 oz of fluid every hour Older adults with cognitive deficits may forget to consume liquids. while awake. Prompting such patients to drink fluids should be an essential part of their plan of care. • Be sure fluids are within reach of the patient confined to bed. For those confined to bed or with restricted movement, this action is a simple, basic measure to promote fluid intake. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying risk factors pertinent Early intervention in risk situations can prevent dehydration. to the situation: � Diabetes � Protein malnourishment � Extremes of age � Excessive vomiting or diarrhea � Medication for fluid retention or high blood pressure � Confusion or lethargy � Fever � Excessive blood loss � Wound drainage � Inability to obtain adequate fluids because of pain, immobility, or difficulty in swallowing • Assist the client and family in identifying lifestyle changes that Avoidance of dehydrating activities will prevent excessive fluid loss. may be required: � Avoiding excessive use of caffeine, alcohol, laxatives, diuretics, antihistamines, fasting, and high-protein diets � Using salt tablets � Exercising without electrolyte replacement Copyright © 2002 F.A. Davis Company 128 NUTRITIONAL-METABOLIC PATTERN Fluid Volume, Deficient, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Total intake and output (I and O) for last 24 h. Is there no more than 200 mL difference between I and O? Yes No Record

data, e.g., in last 24 h, Reassess using initial assessment factors. I  2500 mL, O  2700 mL; 200 mL difference. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., in last 24 h, I  2200 mL, O  2700 mL; Did evaluation show another 500 mL difference. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company FLUID VOLUME, EXCESS 129 Fluid Volume, Excess 12. Blood pressure changes 13. Pulmonary artery pressure changes DEFINITION 14. Oliguria 15. Specific gravity changes The state in which an individual experiences increased fluid reten- 16. Azotemia tion and edema.30 17. Altered electrolytes 18. Restlessness NANDA TAXONOMY: DOMAIN 2—NUTRITION; 19. Anxiety CLASS 5—HYDRATION 20. Anasarca 21. Abnormal breath sounds, rales (crackles) NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 22. Edema CLASS N—TISSUE PERFUSION MANAGEMENT 23. Increased central venous pressure NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 24. Positive hepatojugular reflex CLASS G—FLUID AND ELECTROLYTES RELATED FACTORS30 DEFINING CHARACTERISTICS30 1. Compromised regulatory mechanisms 1. Jugular vein distention 2. Excess fluid intake 2. Decreased hemoglobin and hematocrit 3. Excess sodium intake 3. Weight gain over short period 4. Dyspnea RELATED CLINICAL CONCERNS 5. Intake exceeds output 6. Pleural effusion 1. Congestive heart failure 7. Orthopnea 2. Renal failure 8. S 3. Cirrhosis of the liver 3 heart sounds 9. Pulmonary congestion 4. Cancer 10. Change in respiratory pattern 5. Toxemia 11. Change in mental status HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Decreased Cardiac Output and Impaired Gas addition to the other changes in the body’s Exchange The body depends on both appropriate physiology. gas exchange and adequate cardiac output to Urinary Retention One way the body oxygenate tissues and circulate nutrients and compensates fluid balance is through urinary fluid for use and disposal. If either of these is elimination. If the body cannot properly eliminate compromised, then the body will suffer in some fluids, then the system “backs up” so to speak, and way. One of the major ways the body suffers is in excess fluid remains in the tissues. the circulation of body fluid. Fluid will be left in Impaired Physical Mobility Besides appropriate gas tissue and not absorbed into the general exchange and adequate cardiac output, the body circulation to be redistributed or eliminated. also needs movement of muscles to assist in Imbalanced Nutrition, More Than Body transporting food and fluids to and from the tissue. Requirements This diagnosis could be the Impaired Physical Mobility might lead to an primary problem. The person ingests more food alteration in movement of food and fluids. Waste and fluid than the body can metabolize and products of metabolism and excess fluid are allowed eliminate. The result is excess fluid volume in to remain in tissues, creating a fluid volume excess. ADDITIONAL INFORMATION EXPECTED OUTCOME Excess fluid volume can occur as a result of water excess, sodium Intake and output will balance within 200 mL by [date]. (Note: May excess, or water and sodium excess.58 Careful assessment and mon- want difference to be only 50 mL for a child.) itoring is needed to recognize the difference in precipitating causes. Edema: Mild or 1
means that the skin can be depressed 0 to 1⁄4 TARGET DATES inch; moderate or 2
means that the skin can be depressed 1⁄4 to 1⁄2 inch; severe or 3
means that the skin can be depressed 1⁄2 to 1 inch; In a healthy person, intake and output reach an approximate bal- and deep pitting edema or 4
means that the skin can be depressed ance over a span of 72 hours. An acceptable target date would then more than 1 inch and it takes longer than 30 seconds to rebound. logically be the third day after admission. Copyright © 2002 F.A. Davis Company 130 NUTRITIONAL-METABOLIC PATTERN NURSING ACTIONS/ INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Take vital signs every 2 h at [state times here], and include Permits monitoring of cardiovascular response to illness state and apical pulse. therapy. • Check lung, heart, and breath sounds every 2 h on [odd/even] Essential monitoring for fluid collection in lungs and cardiac hour. overload due to edema. • Elevate head of bed. Facilitates respiration. • Measure and record total intake and output every shift. Assists in determining amount of fluid retention and need for fluid limitation. • Check intake and output hourly (urinary output not less than 30 mL/h). • Observe and document color and character of urine, vomitus, and stools. • Check urine specific gravity at least every 2 h on [odd/even] hour. • Monitor: Essential monitoring for fluid and electrolyte imbalance. � Skin turgor at least every 4 h while awake [note times here]. � Electrolytes, hemoglobin, and hematocrit. Collaborate with physician regarding frequency of laboratory tests. � Mental status and behavior at least every 2 h on [odd/even] hour. • Weigh daily at [state times here]. Monitoring for fluid replacement. Allows consistent comparison of weight. • Weigh at same time each day and in same-weight clothing. • Administer medication (e.g., diuretics) as ordered. Monitor medication effects. • Collaborate with physician regarding restricting intake: Restricting fluids prevents cardiovascular system overload and � Amount reduces workload on renal system. � Type, e.g., clear fluids only or intravenous only • Turn and properly position the patient at least every 2 h on Prevents stasis of fluids in any one part of body. Assists in [odd/even] hour. circulation of fluid and in preventing skin integrity problems. • Check dependent parts for edema (e.g., ankles, sacral area, and buttocks). • Protect edematous skin from injury: � Avoid shearing force. � Use powder or cornstarch to avoid friction. � Use pillows, foam rubber pads, etc. to avoid pressure. � Encourage the patient to alter position frequently. � Provide active and passive ROM every 4 h while awake at [state times here]. • Administer or assist with complete oral hygiene after each meal Cleans and lubricates the mouth. Permits the patient to more fully and at bedtime. enjoy foods and fluid allowed. • Teach the patient to monitor own intake and output at home. Supports the patient’s self-care by pointing out measures he or she can use to control fluid imbalance. Adequate intake and early intervention will prevent undesirable outcomes. • In collaboration with dietitian: Cost-effective use of readily available resources. Promotes � Obtain nutritional history. interdisciplinary care, thus, better care for the patient. � Begin high-protein diet (80–100 g protein). � Reduce sodium intake (not more than 6 g daily or less than 2.5 g daily). • Refer to other health care professionals as appropriate. Child Health ACTIONS/INTERVENTIONS RATIONALES • Measure and record total intake and output every shift: A strict assessment of intake and output serves to guide treatment � Check intake and output hourly, and weigh diapers. for indication of hydration status. The specific gravity assists in � Monitor specific gravity at least every 2 h or as specified. determining cardiac, renal, and respiratory function and electrolyte status. (continued) Copyright © 2002 F.A. Davis Company FLUID VOLUME, EXCESS 131 (continued) ACTIONS/INTERVENTIONS RATIONALES • Reposition as tolerated every half-hour. Prevents stasis of fluids in any one part of body. Assists in circulation of fluid and in preventing skin integrity problems. • Weigh daily at same time under same conditions of dress Accuracy of weight is critical, serves as a major indicator for (infants without clothes, children in underwear). treatment effectiveness, and is an ongoing parameter for treatment. • Administer medications as ordered with attention to appropriate Potassium and sodium alterations may be present and must be dosage and potential effect on electrolytes. addressed to prevent further fluid or electrolyte imbalance. • Anticipate potential for respiratory distress and monitor Fluid overload and fluid and electrolyte deviations may lead to appropriately by cautious checking of breath sounds, respiratory and/or cardiac arrest if undetected or untreated. respiratory effort, and level of consciousness. • Administer fluids per IV with appropriate equipment; i.e., Likelihood of iatrogenic fluid overdose is lessened with Buretrol and clamping off main supply of fluids even while on appropriate safeguards. IV pump and placing 2 h of fluid at a time in Buretrol or as stated. Women’s Health NOTE: Pregnancy-induced hypertension (PIH), often called the “disease of theories,” has been docu- mented for the last 200 years. Numerous causes have been proposed but never substantiated; how- ever, data collected during this time does support the following: 1. Chorionic villi must be present in the uterus for a diagnosis of PIH to be made. 2. Women exposed for the first time to chorionic villi are at increased risk for developing PIH. 3. Women exposed to an increased amount of chorionic villi, for example, multiple gestation or hydatidiform mole, are at greater risk for developing PIH. 4. Women with a history of PIH in a previous pregnancy are at increased risk for developing PIH. 5. Women who change partners are more likely to develop PIH in a subsequent pregnancy. 6. There is a genetic predisposition for the development of PIH, which may be a single gene or multifactorial. 7. Vascular disease places the patient at greater risk for developing superimposed PIH.57 ACTIONS/INTERVENTIONS RATIONALES • Review the client’s history for factors associated with Basic database required to assess for potential of PIH. pregnancy-induced hypertension (PIH): � Family and personal history such as diabetes or multiple gestation � Rh incompatibility or hypertensive disorder � Chronic blood pressure 140/90 mm Hg or greater prior to pregnancy, or in the absence of a hydatidiform mole, that persists for 42 days post partum • During current pregnancy, observe for following characteristics Increased knowledge for the patient will assist the patient with of PIH: earlier help-seeking behaviors. � Nulliparous women younger than 20 or older than 35 yr of age � Multipara with multiple gestation or renal or vascular disease � Presence of hydatidiform mole • Monitor the patient for chronic hypertension:58 � Increase in systolic blood pressure of 30 mm Hg or diastolic blood pressure of at least 15 mm Hg above baseline on two occasions at least 2 h apart � Development of proteinuria • Monitor and teach the patient to immediately report the following signs of PIH: � Increase of 30 mm Hg in blood pressure or 140/90 blood pressure and above � Edema: Weight gain of 5 lb or greater in 1 wk � Proteinuria: 1 g/L or greater of protein in a 24-h urine collection (2
by dipstick) � Visual disturbances: blurring of vision or headaches � Epigastric pain • Observe closely for signs of severe preeclampsia in any patient Knowledge of the complexity and multisystem nature of the who presents with57: disease assists with early detection and treatment. (continued) Copyright © 2002 F.A. Davis Company 132 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Blood pressure greater than or equal to 160 mm Hg systolic, or greater than or equal to 110 mm Hg diastolic, on at least two occasions 6 h apart with the patient on bedrest � Proteinuria greater than or equal to 5 g in 24 h or 3
to 4
on qualitative assessment � Oliguria: less than 400 mL in 24 h � Cerebral or visual disturbances � Epigastric pain � Pulmonary edema or cyanosis � Impaired liver function of unclear etiology � Thrombocytopenia • Monitor, at least once per shift, for edema. Teach the patient to: Increased knowledge for the patient will assist the patient with � Monitor swelling of hands, face, legs, or feet. (Caution: May earlier help-seeking behaviors. need to remove rings.) � Be aware of a possible need to wear loose shoes or a bigger shoe size. � Schedule rest breaks during day and to elevate feet. � When lying down, to lie on left side to promote placental perfusion and prevent compression of vena cava. • In collaboration with dietitian: � Obtain nutritional history. � Place the patient on high-protein diet (80–100 g protein). � Place the patient on reduced sodium intake (not more than 6 g daily or less than 2.5 g daily). • Monitor: � Intake and output: urinary output not less than 30 mL/h or

120 mL/4 h � Effect of magnesium sulfate (MgSO4) and hydralazine hydrochloride (Apresoline) therapy (have antidote for MgSO4 [calcium gluconate] available at all times during MgSO4 therapy) � Deep tendon reflexes (DTR) at least every 4 h [state times Basic safety measures. here] � Respiratory rate, pulse, and blood pressure at least every 2 h on the [odd/even] hour � Fetal heart rate and well-being at least every 2 h on the [odd/even] hour • Institute seizure precautions. • Ensure bedrest and reduction of noise level in the patient’s Decreases sensory stimuli that might increase the likelihood of a environment. seizure. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Observe chronic psychiatric clients and clients with preexisting A pattern of extreme polydipsia and polyuria can develop in alcoholism59 for signs and symptoms of polydipsia and/or water clients with psychiatric disorders. This may be related to intoxication. The observations include59–61: dopamine central nervous system activity and dysfunction in � Frequent trips to sources of fluid and excessive consumption antidiuretic hormone activity in combination with psychosocial of fluids factors. The sense of thirst can also be increased by certain � Client stating, “I feel as if I have to drink water all of the time,” medications.60,61 or a similar statement � Fluid-seeking behavior � Dramatic or rapid fluctuations in weight � Polyuria � Incontinence � Carrying large cups � Urine specific gravity of 1.008 or less59 � Decreases in serum sodium (continued) Copyright © 2002 F.A. Davis Company FLUID VOLUME, EXCESS 133 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss the client’s explanations for excessive drinking to Determining exact reason for polydipsia allows for more effective determine causes of excessive fluid intake. If it is determined intervention. that drinking is a diversionary activity or an attempt to avoid interaction, implement nursing actions for Social Isolation and/or Deficient Diversional Activity as appropriate. If it is determined that fluid intake is related to testing concern of staff or testing limits, refer to nursing actions for Powerlessness or Self-Esteem disturbances. • If it is determined that the client is at risk for water intoxication, Water intoxication can be life-threatening.59 implement the following actions: � Monitor and document fluid intake and output and weight fluctuations on a daily basis. � Restrict fluids as ordered by physician. • Provide small medicine cup (30 mL) for the client to obtain fluids. • Provide fluids such as chipped ice on a schedule. Note schedule here. • Instruct the client in need for reducing nicotine consumption. Nicotine increases release of antidiuretic hormone (ADH), a If the client cannot do this, it may be necessary to initiate a water-conserving hormone.59 “rationing” plan. If so, note plan here. • Provide the client with sugarless gum and/or hard candy to decrease dry mouth. Note the client’s preference. • Identify with the client those activities that would be most helpful in diverting attention from fluid restriction. Note specific activities here with schedule for use. • Refer to occupational and recreational therapists. • If the client continues to have difficulty restricting fluids, provide increased supervision by limiting the client to day area or other group activity rooms where he or she can be observed. Note restrictions here. If necessary, place the client on one-to-one observation. • Talk with the client about feelings engendered by restrictions for 15 min per shift. Note times here. • Discuss the client’s restriction in a community meeting if: � Restrictions are impacting others on the unit. � Support from peers would facilitate client’s maintaining restrictions. • Provide positive verbal support for the client’s maintaining Promotes the client’s self-esteem and provides motivation for restriction(s). continued efforts. • Identify with the client appropriate rewards for maintaining Promotes the client’s self-esteem and sense of control and restrictions and reaching goals. Describe rewards and provides motivation for continuing his or her efforts. behaviors necessary to obtain rewards here. Gerontic Health Nursing actions for the gerontic health patient with this nursing diagnosis are the same as those for Adult Health and Home Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach methods to protect edematous tissue: Tissue is at risk for injury. The client and family can be taught to � Practice proper body alignment. minimize risks and damage. � Use pillows, pads, etc. to relieve pressure on dependent parts. � Avoid shearing force when moving in bed or chair. � Alter position at least every 2 h. • Assist the client and family to set criteria to help them determine Planned decision making to prepare for potential crisis. when a physician or other intervention is required. • Assist the client and family in identifying risk factors pertinent to Identification of risk factors and understanding of relationship to the situation, e.g., heart disease, kidney disease, diabetes mellitus, fluid excess provide for intervention to reduce or prevent negative diabetes insipidus, liver disease, pregnancy, or immobility. outcomes. (continued) Copyright © 2002 F.A. Davis Company 134 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach signs and symptoms of fluid excess: Early recognition of signs and symptoms provides data for early � Peripheral and dependent edema intervention. � Shortness of breath � Taut and shiny skin • Assist the client and family in identifying lifestyle changes that Knowledge and support provide motivation for change and may be required: increase potential for positive outcome. � Avoid standing or sitting for long periods of time; elevate edematous limbs. � Avoid crossing legs. � Avoid constrictive clothing (girdles, garters, knee-high stockings, rubber bands to hold up stocking, etc.). � Consider wearing antiembolism stockings. � Avoid excess salt. Teach the patient and family to read labels for sodium content. Avoid canned and fast foods. � Use spices other than salt in cooking. � Avoid lying in one position for longer than 2 h. � Raise head of bed or sit in chair if having difficulty breathing. � Restriction of fluid intake as necessary (e.g., usual in kidney and liver disease). � Weigh at the same time every day wearing the same clothes and using the same scale. • Teach purposes and side effects of medication, e.g., diuretics or Appropriate use of medication and reduction of side effects. cardiac medications. Copyright © 2002 F.A. Davis Company FLUID VOLUME, EXCESS 135 Fluid Volume, Excess FLOWCHART EVALUATION: EXPECTED OUTCOME Total intake and output (I and O) for last 24 h. Is there no more than 200 mL difference between I and O? Yes No Record data, e.g., in last 24 h, Reassess using initial assessment factors. I  2000 mL, O  1840 mL; difference  160 mL. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., in last 24 h, I  1500 mL, O  500 mL; Did evaluation show another difference  1000 mL. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 136 NUTRITIONAL-METABOLIC PATTERN Fluid Volume, Imbalanced, Risk for DEFINING CHARACTERISTICS30 DEFINITION None given. A risk of a decrease, increase, or rapid shift from one to the other RISK FACTORS30 of intravascular, interstitial, and/or intracellular fluid. This refers to the loss or excess or both of body fluids or replacement fluids.30 1. Scheduled for major invasive procedures 2. Other risk factors to be determined NANDA TAXONOMY: DOMAIN 2—NUTRITION; CLASS 5—HYDRATION RELATED CLINICAL CONCERNS NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 1. Any major surgical procedure CLASS N—TISSUE PERFUSION MANAGEMENT 2. Any kidney or adrenal gland disease 3. Hemorrhage NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 4. Burns CLASS G—FLUID AND ELECTROLYTES 5. Any disease impacting the intestines HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Risk for Deficient Fluid Volume This diagnosis be used until the nurse can definitively evaluate in refers to the danger of fluid loss, whereas Risk for which direction the fluid shift is going. Imbalanced Fluid Volume can be either a deficit or Excess Fluid Volume This is an actual diagnosis an excess. Risk for Fluid Volume Imbalance should and signifies a fluid overload. EXPECTED OUTCOME TARGET DATES Will not exhibit any signs or symptoms of deficient fluid volume or In a healthy person, intake and output reach an approximate bal- excess fluid volume by [date]. ance over a span of 72 hours. An acceptable target date would then logically be the third day after admission. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Measure and record total intake and output every shift. Determines fluid loss or fluid retention and need for replacement or restriction of fluids. • Check intake and output hourly. • Observe and document color and consistency of all urine, stools, and vomitus. • Check urine specific gravity every 4 h at [state times here]. • Take vital signs every 2 h on [odd/even] hour and include apical Permits monitoring of cardiovascular response to illness state and pulse. therapy. • Check lung, heart, and breath sounds every 2 h on [odd/even] hour. • Elevate head of bed as needed. Facilitates respiration. • Monitor intravenous fluids. • Monitor: Essential monitoring for fluid and electrolyte balance. � Skin turgor at least every 4 h at [state times here] while awake � Electrolytes, blood urea nitrogen, hematocrit, and hemoglobin (Collaborate with physician regarding frequency of laboratory tests.) � Central venous pressure every hour (if appropriate) Essential monitoring for fluid collection in lungs and cardiac � Mental status and behavior at least every 2 h on [odd/even] overload due to edema. hour (continued) Copyright © 2002 F.A. Davis Company FLUID VOLUME, IMBALANCED, RISK FOR 137 (continued) ACTIONS/INTERVENTIONS RATIONALES � For signs and symptoms of shock at least every 4 h at [state times here], e.g., weakness, diaphoresis, hypotension, tachycardia or tachypnea • Weigh daily at [state time here]. Teach the patient to weigh at Monitoring for fluid replacement. Allows consistent comparison same time each day in same-weight clothing. of weight. • If there is a fluid volume deficit, force fluids to a minimum of 2000 mL daily. � Determine the patient’s fluid likes and dislikes. (List here.) Prevents dehydration and easily replaces fluid loss without Consult with dietary. resorting to IVs. � Offer small amount of fluid (4–5 oz) at least every hour while Frequent fluids improve hydration. Variation in fluids is helpful to awake and at every awakening during night. encourage the patient to increase intake. � Offer fluids at temperature that is most acceptable to the patient, i.e., warm or cool. � Intersperse fluids with high-fluid-content foods, e.g., popsicles, gelatin, pudding, ice cream, or watermelon. Note the patient’s preferences here. • Check dependent parts for edema, e.g., ankles, sacral area, and buttocks. • If there is fluid volume excess, collaborate with physician about Restricting fluids prevents cardiovascular system overload and restricting fluids. Also protect skin from injury: reduces workload on renal system. � Avoid shearing force. � Use powder or cornstarch to avoid friction. Prevents skin integrity problems. � Use pillows, foam rubber pads, etc. To avoid pressure. • Administer medications as ordered. Monitor medication effects. • Assist the patient to eat and drink as necessary. Provide positive verbal support for patient. • Administer or assist with oral hygiene after each meal and Cleans and lubricates the mouth. Encourages the patient to eat before bedtime. and drink as allowed. • Turn and properly position the patient at least every 2 h on [odd/even] hour. • Encourage the patient to alter position frequently. Prevents stasis of fluids in any one part of body. Assists in circulation of fluid and in preventing skin integrity problems. • Provide active and passive ROM every 4 h at [state times here] while awake. • Schedule at least 1-h rest periods for patient at least 4 times a Prevents overexertion and extra strain on circulatory system. day at [times]. Child Health ACTIONS/INTERVENTIONS RATIONALES • Ascertain for at-risk populations, especially those infants and Greater likelihood exists for fluid volume imbalances with infants children scheduled for surgery or procedures in which NPO or children who undergo surgery during which fluids may be lost status is necessary. or gained in a short period of time. • Determine preoperatively or prior to onset of procedures the Anticipatory planning provides appropriate focus on risk for deficit ongoing fluid plan for the client with

specifications for: or overload for vulnerable infants and children in advance of actual � Type of fluid and status of oral feedings occurrence. � Rate of administration of IV fluid � Electrolyte status and additives to be administered � Accurate weight � Accurate 24-hour intake and output � Recent essential preoperative laboratory tests with abnormal results addressed � Allowance for special drainage or physiologic demands � Past 24-h specific gravity record • Identify appropriate parameters to be addressed by all members Pre-identification of coordination of multidisciplinary specialists of the health care team during and after surgery or procedure to assists in appropriate fluid maintenance. include cardiac, renal, neurologic, metabolic, and related physiologic alterations. (continued) Copyright © 2002 F.A. Davis Company 138 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Maintain the patient’s temperature during and after surgery or Metabolic demands are lessened in the absence of cold stress or procedure. hyperthermia. Women’s Health NOTE: Bleeding during pregnancy, delivery, and post partum can rapidly occur. There is potential for maternal exsanguination within 8 to 10 min because of the large amount of blood flow to the uterus and placenta during pregnancy. ACTIONS/INTERVENTIONS RATIONALES • Monitor the patients presenting to labor and delivery for signs and symptoms of: � Severe abruptio-persistent uterine contractions Abruptio placentae accounts for approximately 15 percent of all � Shock out of proportion to blood loss perinatal deaths. � Rigid, tender, localized uterine pain, and tetanic contractions � Bright red bleeding without pain Placenta previa occurs in 0.005 percent of pregnancies but has a reoccurrence rate of 4 to 8 percent. • Carefully monitor for uterine involution and signs and Subinvolution, retained products of conception, uterine atony, and symptoms of bleeding during delivery and post partum. lacerations of the birth canal are the leading causes of postpartum hemorrhage. Psychiatric Health The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health. Gerontic Health NOTE: See interventions for Adult Health. Older adults are at risk for this diagnosis as a result of ag- ing changes that affect the ability to respond to volume changes. Renal system changes make responses to volume overload or depletion difficult. Older adults experience a delayed response to a decrease in sodium and are at higher risk for volume depletion. A delay in the ability to excrete salt and water leads to an increased risk for fluid overload and hyponatremia. Postoperatively, the older adult may have ex- cessive or prolonged aldosterone/ADH responses, causing difficulty eliminating excess fluids. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the client for the presence of ascites (e.g., abdominal Prevents complications of fluid shifts. distention with weight gain) or edema and report to physician. • Monitor for signs of dehydration: Dehydration may accompany fluid shifts such as ascites or edema. � Dry tongue and skin � Sunken eyeballs � Muscle weakness � Decreased urinary output • Educate the client and caregivers about the importance of Promotes normal fluid balance. adhering to a sodium-restricted diet (e.g., 250–500 mg per day). • Educate the client and caregivers about medications prescribed Promotes compliance with prescribed medications. to control the fluid volume imbalance (e.g., potassium-sparing diuretics) and possible side effects. • Assist the client in obtaining supplies necessary to measure Basic monitoring for imbalances. intake and output, and teach the client and caregivers how to measure and record intake and output. • Monitor balance each nursing visit. Allows for early identification of progressing fluid imbalances. Copyright © 2002 F.A. Davis Company FLUID VOLUME, IMBALANCED, RISK FOR 139 Fluid Volume, Imbalanced, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient exhibit any signs or symptoms of either fluid volume deficit or fluid volume excess? Yes No Reassess using initial assessment factors. Record data, e.g., intake and output balanced for past 10 days; skin turgor within normal limits; consistent weight. Record RESOLVED. Delete nursing diagnosis, expected outcome, target Is diagnosis validated? date, and nursing actions. Did evaluation show another Yes No problem had developed? Record data, e.g., intake and output balance fluctuating from 1200 mL to
1500 mL. Skin turgor changing Yes No 2
edema to dehydration. Weight fluctuating between 10 lb gain to 10 lb loss. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company 140 NUTRITIONAL-METABOLIC PATTERN Hyperthermia RELATED FACTORS30 DEFINITION 1. Illness or trauma 2. Increased metabolic rate A state in which an individual’s body temperature is elevated above 3. Vigorous activity his or her normal range.30 4. Medications or anesthesia 5. Inability or decreased ability to perspire NANDA TAXONOMY: DOMAIN 11—SAFETY/ 6. Exposure to hot environment PROTECTION; CLASS 6—THERMOREGULATION 7. Dehydration 8. Inappropriate clothing NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; CLASS M—THERMOREGULATION RELATED CLINICAL CONCERNS NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS I—METABOLIC REGULATION 1. Any infectious process 2. Septicemia 3. Hyperthyroidism DEFINING CHARACTERISTICS30 4. Any disease leading to dehydration, for example, diarrhea, vom- iting, hemorrhage 1. Increase in body temperature above normal range 5. Any condition causing pressure on the brainstem 2. Seizures or convulsion 6. Heat stroke 3. Flushed skin 4. Increased respiratory rate 5. Tachycardia 6. Warm to touch HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Risk for Imbalanced Body Temperature This and being subnormal. In Hyperthermia, the diagnosis indicates that the person is potentially temperature does not fluctuate; it remains elevated unable to regulate heat production and dissipation until the underlying cause of the elevation is within a normal range. In Hyperthermia, the negated or until administration of medications patient’s ability to produce heat is not impaired. such as Tylenol and aspirin show a definitive effect Heat dissipation is impaired to the degree that on the elevation. Hyperthermia results. Hypothermia Hypothermia means the patient’s Ineffective Thermoregulation Ineffective body temperature is subnormal. This indicates Thermoregulation indicates that the patient’s body the exact opposite measurement from temperature is fluctuating between being elevated Hyperthermia. EXPECTED OUTCOME TARGET DATES Will return to normal body temperature (range between 97.3 and Because hyperthermia can be life-threatening, initial target dates 98.8F) by [date]. should be in terms of hours. After the patient has demonstrated some stability toward a normal range, the target date can be in- creased to 2 to 4 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor temperature every hour on the [hour/half hour] while Hyperthermia is incompatible with cellular life. awake and temperature remains elevated. Measure temperature every 2 h during night [note times here]. After temperature begins to decrease, lengthen time between temperature measurements. (continued) Copyright © 2002 F.A. Davis Company HYPERTHERMIA 141 (continued) ACTIONS/INTERVENTIONS RATIONALES • Sponge the patient with cool water or rubbing alcohol, or apply Basic measures to assist in temperature reduction via heat continuous cold packs, or place the patient in a tub of tepid dissipation. Overchilling could cause shivering, which increases water until temperature is lowered to at least 102F. (Be careful heat production. not to overchill the patient.) Dry the patient well and keep dry and clean. • Use a fan or place the patient in front of an air conditioner. Promotes cooling via heat dissipation. Cool environment to no more than 70F. • Monitor and use equipment according to manufacturer’s guidelines and policies of unit, e.g., cooling blanket. • Give antipyretic drugs as ordered. Closely monitor effects, and Antipyretics assist in temperature reduction. Monitoring ensures document effects within 30 min after medications given. that the patient is not changed to a condition of hypothermia; it allows the health care team to assess the effectiveness of the antipyretic. Ineffectiveness would require changing to a different antipyretic. • Maintain seizure precautions until temperature stabilizes. Hyperthermia can lead to febrile seizures as a result of overstimulation of the nervous system. • Give sips of salt water every 30 min, if conscious and not Assists in maintaining fluid and electrolyte balance. vomiting. • Encourage fluids up to 3000 mL every 24 h. Helps maintain fluid and electrolyte balance and assists in replacing fluid lost through perspiration. • Give skin, mouth, and nasal care at least every 4 h while awake Hyperthermia promotes mouth breathing in an effort to dissipate [note times here]. Change bed linens and pajamas as often as heat. Mouth breathing dries the oral mucous membrane. Keeping necessary. bed linens and pajamas dry helps avoid shivering. • Do not give stimulants. Stimulants cause vasoconstriction, which could increase hyperthermia. • Gather data relevant to underlying contributing factors at least Control of underlying factors helps prevent occurrence of once per shift. hyperthermia. • Provide health care teaching, beginning on admission, regarding: Relieves anxiety and allows the patient and family to participate in � Need for frequent temperature checks care. Initiates home care planning. � Related medical or nursing care � Safety needs when using ice packs or electric cooling blanket � How family can assist in care � Importance of hydration � Possible fear or altered comfort of patient with fever because of discomfort, fast heart rate, dizziness, and general feeling of illness � Possible seizure activity • Carry out appropriate infection control in the event or potential Prevents spread of infection. event of infectious disease process according to actual or suspected organisms. • Assist in promoting a quiet environment. Allows for essential sleep and rest. Hyperthermia causes increased metabolic rate. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor temperature every 30 min until temperature stabilizes. Frequent assessment per tympanic (aural) thermometer or as specified provides cues to evaluate efficacy of treatment and monitors underlying pathology. • Administer antipyretic, antiseizure, or antibiotic medications as Unique components for each individual patient must be considered ordered with precaution for: within usual treatment modalities to help bring safe and timely � Maintenance of IV line return of temperature while avoiding iatrogenic complications. � Drug safe range for the child’s age and weight � Potential untoward response � IV compatibility � The infant’s or child’s renal, hepatic, and GI status • Provide padding to siderails of crib or bed to prevent injury in Protection from injury in likelihood of uncontrolled sudden bodily event of possible seizures. movement serves to protect the patient from further problems. Uses universal seizure precautions. (continued) Copyright © 2002 F.A. Davis Company 142 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Ensure that airway maintenance is addressed by appropriate As a part of seizure activity, there is always the potential of loss of suctioning and airway equipment according to age. consciousness with respiratory involvement. Women’s Health NOTE: Newborn is included with Women’s Health because newborn care is administered by nurses on either a maternity, obstetric, or mother-baby unit. ACTIONS/INTERVENTIONS RATIONALES • When under heat source or bililights, monitor the infant every Provides safe environment for the infant. hour for increased redness and sweating. Check heat source at least every 30 min (overhead, isolettes, or bililights). • Monitor the infant’s temperature, skin turgor, and fontanels Provides essential information as to the infant’s current status and (bulging or sunken) for signs and symptoms of dehydration promotes a safe environment for the infant. every 30 min while under heat source. First temperature measurement should be rectal; thereafter can be axillary. • Check for urination; the infant should wet at least 6 diapers Basic monitoring of the infant’s physiologic functioning. every 24 h. • Replace lost fluids by offering the infant breast, water, or Decreases insensible fluid loss and maintains body temperature formula at least every 2 h on [odd/even] hour. within normal range. This action decreases the infant’s needs for IV glucose. • Pregnancy Provides safe environment for the mother and prevents injury to � Teach the patient to avoid use of hot tubs or saunas. the fetus. (1) During first trimester: Concerns about possible CNS defects in fetus and failure of neural tube closure.62 (2) During second and third trimesters: Concerns about cardiac load for mother.62 � Provide cooling fans for mothers during labor and for patients on MgSO4 therapy. � Keep labor room cool for the mother’s comfort. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor clients receiving neuroleptic drugs for decreased Clients who are receiving neuroleptic medications are at risk for ability to sweat by observing for decreased perspiration and an developing neuroleptic malignant syndrome, which can be increase in body temperature with activity, especially in warm life-threatening.58

weather. Monitor these clients for hyperpyrexia (up to 107F). Notify physician of alterations in temperature. Note alteration in the client’s plan of care and initiate the following actions: � The client should not go outside in the warmest part of the day during warm weather. � Maintain the client’s fluid intake up to 3000 mL every 24 h by (this is especially important for clients who are also receiving lithium carbonate; lithium levels should be carefully evaluated): (1) Having client’s favorite fluids on the unit. (2) Having the client drink 240 mL (an 8-oz glass) of fluids every hour while awake and 240 mL with each meal. If necessary, the nurse will sit with the client while the fluid is consumed. (3) Maintaining record of the client’s intake and output. � Dress the client in light, loose clothing. � If the client is disoriented or confused, provide one-to-one High fevers can alter mental status and thus decrease the client’s observation. ability to make proper judgments. (continued) Copyright © 2002 F.A. Davis Company HYPERTHERMIA 143 (continued) ACTIONS/INTERVENTIONS RATIONALES • Decrease the client’s activity level by: Increased physical activity increases body temperature, and the � Decreasing stimuli decreased ability to sweat, secondary to medications, inhibits the � Sitting with the client and talking quietly, or involving the body’s normal adaptive response.58 client in a table game or activity that requires little large muscle movement [note activities that that client enjoys here] � Assigning room near nurse’s station and dayroom areas • Monitor the client’s mental status every hour. • Do not provide clients with alteration in mental status with small electrical cooling devices unless they receive constant supervision. • Give the client as much information as possible about his or her condition and measures that are implemented to decrease temperature. • Teach the client and family measures to decrease or eliminate risk for hyperthermia (see Home Health for teaching information). • Consult with appropriate assistive resources as indicated. Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those for Adult Health and Home Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to hyperthermia (see Defining Identification of risk factors provides for intervention to reduce or Characteristics). prevent negative outcomes. • Teach the client and family signs and symptoms of hyperthermia. Provides data for early intervention. � Flushed skin � Increased respiratory rate � Increased heart rate � Increase in body temperature � Seizure precautions and care • Teach measures to decrease or eliminate the risk of hyperthermia: Provides basic knowledge that increases the probability of � Wearing appropriate clothing successful self-care. � Taking appropriate care of underlying disease � Avoiding exposure to hot environments � Preventing dehydration � Using antipyretics � Performing early intervention with gradual cooling • Involve the client and family in planning, implementing, and Involvement provides opportunity for increased motivation and promoting reduction or elimination of the risk for hyperthermia. ability to appropriately intervene. • Assist the client and family to identify lifestyle changes that may Knowledge and support provide motivation for change and be required: increase potential for a positive outcome. � Measure temperature using appropriate method for developmental age of person. � Learn survival techniques if the client works or plays outdoors. � Ensure proper hydration. � Transport to health care facility. � Use emergency transport system. Copyright © 2002 F.A. Davis Company 144 NUTRITIONAL-METABOLIC PATTERN Hyperthermia FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient’s temperature measurement within the normal range? Yes No Record data, e.g., rectal temperature Reassess using initial assessment factors. measurement has ranged from 98 to 100°F for past 4 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., rectal temperature measurement Did evaluation show another has remained over 101°F problem had arisen? Yes for past 2 days. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company HYPOTHERMIA 145 Hypothermia 8. Slow capillary refill 9. Tachycardia DEFINITION RELATED FACTORS30 The state in which an individual’s body temperature is reduced below normal range.30 1. Exposure to cool or cold environment 2. Medications causing vasodilation NANDA TAXONOMY: DOMAIN 11—SAFETY/ 3. Malnutrition PROTECTION; CLASS 6—THERMOREGULATION 4. Inadequate clothing 5. Illness or trauma NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 6. Evaporation from skin in cool environment CLASS M—THERMOREGULATION 7. Decreased metabolic rate NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 8. Damage to hypothalamus CLASS I—METABOLIC REGULATION 9. Consumption of alcohol 10. Aging 11. Inability or decreased ability to shiver DEFINING CHARACTERISTICS30 12. Inactivity 1. Pallor (moderate) 2. Reduction in body temperature below normal range RELATED CLINICAL CONCERNS 3. Shivering (mild) 1. Hypothyroidism 4. Cool skin 2. Anorexia nervosa 5. Cyanotic nail beds 3. Any injury to the brainstem 6. Hypertension 7. Piloerection HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Risk for Imbalanced Body Temperature This Ineffective Thermoregulation The body diagnosis indicates that the person is potentially temperature fluctuates between being too high and unable to regulate heat production and heat too low. In Hypothermia, the temperature does not dissipation within a normal range. In Hypothermia, fluctuate; it remains low. the patient’s ability to dissipate heat is not Hyperthermia The patient’s temperature is above impaired. Heat production is impaired to the normal, not below normal. degree that Hypothermia results. EXPECTED OUTCOME TARGET DATES Will identify at least [number] measures to use in correcting Hypothermia can be life-threatening; therefore, initial target dates hypothermia. should be in terms of hours. After the patient has demonstrated some stability toward a normal range, target dates can be increased to 2 to 4 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Warm the patient quickly. Use blankets, warming blankets, Basic measures that assist in increasing core temperature and warm water (102–105F), extra clothing, warm drinks, and prevent excess heat dissipation. Heat lamps and hot-water bottles warm room. Do not use a heat lamp or hot-water bottles. warm only a limited area and increase the likelihood of local tissue Prevent air drafts in room. Monitor safe functioning of damage. equipment used in thermoregulation. • Monitor temperature measurement every hour until Assesses effectiveness of therapy. temperature returns to normal levels and stabilizes. • Prevent injury. Gently massage body; however, do not rub a Massage helps stimulate circulation; however, massage of a body part if frostbite is evident. frostbitten area promotes tissue death and gangrene. In frostbite, circulation has to be gradually reestablished through warming. (continued) Copyright © 2002 F.A. Davis Company 146 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Address skin protective needs by frequent monitoring for Hypothermia causes peripheral vasoconstriction, which leads to a breakdown or altered circulation. risk for impaired skin integrity. • Give fluids such as salt and soda solution. Have the patient sip Assists in maintaining fluid and electrolyte balance. Alcohol would slowly (if conscious and not vomiting). Do not give alcohol. promote vasoconstriction. • Monitor respiratory rate, depth, and breath sounds every hour. Hypothermia and its related factors promote the development of Provide for airway suctioning and positioning as needed. respiratory complications. • Bathe with appropriate protection and covering. Prevents heat loss. • Devote appropriate attention to prevention of major Awareness of the complications of hypothermia will help prevent complications such as shock, cardiac failure, tissue necrosis, the complication. infection, fluid and electrolyte imbalance, convulsions or loss of consciousness, respiratory failure, and renal failure. • Administer medications as ordered. • Monitor effects of medication, and record within 30 min after Assists in monitoring effectiveness of therapy. administration. • Obtain a detailed history regarding: � Onset � Related trauma and causative factors � Duration of hypothermia • Provide opportunities for the patient and family to ask questions Decreases anxiety and facilitates home care teaching. and relay concerns by including 30 min for this every shift. [Note times here.] • Allow for appropriate attention to resolution of psychological Helps in reducing patient’s anxiety, and facilitates patient’s trauma, especially in instances of severe exposure to cold at least resolving lingering effects of trauma. once per shift. [Note times here.] • Teach the patient and family measures to decrease or eliminate Permits the patient to participate in self-care, and promotes the risk for hypothermia, to include: compliance to prevent future episodes. � Wearing appropriate clothing when outdoors � Maintaining room temperature at minimum of 65F � Wearing clothing in layers � Covering the head, hands, and feet when outdoors (especially the head) � Removing wet clothing • Teach the patient about the kinds of behavior that increase the risk for hypothermia: � Drug and alcohol abuse � Working, living, or playing outdoors � Poor nutrition, especially when body fat is reduced below normal levels as in anorexia nervosa • Teach the patient and family signs and symptoms of early hypothermia: � Confusion, disorientation � Slurred speech � Low blood pressure � Difficulty in awakening � Weak pulse � Cold stomach � Impaired coordination • Make appropriate arrangements for follow-up after discharge Fosters resources for long-term management in terms of adequate from hospital. Identify support groups in the community for housing, financial resources, and social habits. the patient and family. • Consult with appropriate assistive resources as indicated: Promotes effective long-term management and prevention of future � Obtain an energy audit by public service company to episode. identify possible sources of heat loss. � Refer the patient to social services to provide information on emergency shelters, clothing, and food banks. � Recommend financial counseling if heating the home is financially difficult. Copyright © 2002 F.A. Davis Company HYPOTHERMIA 147 Child Health ACTIONS/INTERVENTIONS RATIONALES • Provide for maintenance of body temperature by hat (stockinette Heat loss is greatest via the head in young infants as well as by for infant) and using open radiant warmer, isolette, or heating convection and evaporation. Suitable maintenance of temperature blanket. by appropriate equipment helps maintain neutral body core temperature. • Incorporate other health care team members to address Provision of support for long-term follow-up places value on the collaborative needs. need for care and the importance of compliance. Assists in reducing anxiety. • Provide teaching to address unknown and necessary information Serves to establish foundation of trust, and provides essential basis for the child and family in terms they can relate to (e.g., for follow-up care. temperature measurement). • Anticipate safety needs according to the patient’s age and Each opportunity for reinforcing the importance of safety as a part development status. of well-child follow-up should not be overlooked. Emphasize caution with rectal thermometer to prevent trauma to anal sphincter and tissue, and caution the family regarding the use of mercury-glass thermometer and breakage. In the event of use of electronic equipment, emphasize the importance of protection to skin, constant surveillance, and unique safety needs per manufacturer. Women’s Health Newborn NOTE: This nursing diagnosis pertains to the woman the same as to any other adult. The reader is re- ferred to the other sections for specific nursing actions pertaining to women and hypothermia. Infants control their body temperature with nonshivering thermogenesis; this process is accompanied by an increase in oxygen and calorie consumption. Therefore, use of a radiant warmer or prewarmed mat- tress for initial care provides environmental heat giving rather than heat losing. However, it is impor- tant to note that hypothermia and cold stress in the neonate are related to the amount of oxygen needed by the infant to control apnea and acid-base balance. It is estimated that to replace a heat loss during a temperature drop of 6.3F, the infant will require a 100 percent increase in oxygen consumption for more than 11⁄2 hour. Metabolic acidosis can occur quickly if the infant becomes hypothermic.43 ACTIONS/INTERVENTIONS RATIONALES • To prevent hypothermia in the newborn: Prevention of heat loss in the infant reduces oxygen and calorie � Dry the new infant thoroughly. consumption and prevents metabolic acidosis. � Cover with blanket. � Lay next to the mother’s body (cover the mother and the infant by placing blanket over them). � Place the infant under radiant heat source. � Keep out of drafts. • Observe the infant for hypothermia. Check temperature every hour until stable, then every 4 h for 24 h. May

be taken rectally, by axilla, or by skin (continuous probe). Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the client’s mental status every 2 h [note times here]; Antipsychotic and antidepressant medications can alter report alterations to physician. thermoregulation, which results in hypothermia.58 • If the client is receiving antipsychotics or antidepressants, report this to the physician when alteration is first noted. • Protect the client from contact with uncontrolled hot objects such as space heaters and radiators by teaching clients and family to remove these from the environment. • Allow the client to use heating pads and electric blankets only Basic safety measures. with supervision. • Teach the client the potential for medication to affect body temperature regulation, especially in the elderly. Copyright © 2002 F.A. Davis Company 148 NUTRITIONAL-METABOLIC PATTERN Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those given in Adult Health and Psychiatric Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning, implementing, and Involvement provides likelihood of increased motivation and ability promoting reduction or elimination of the risk for hypothermia. to appropriately intervene. • Assist the client and family to identify lifestyle changes that may Knowledge and support provide motivation for change and increase be required: the potential for a positive outcome. � Avoiding drug and alcohol abuse � Learning survival techniques if the client works or plays outdoors (e.g., camping, hiking, or skiing) � Keeping person dry � Transporting to health care facility � Using emergency transport system Copyright © 2002 F.A. Davis Company HYPOTHERMIA 149 Hypothermia FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Can the patient identify at least X number of factors that will assist in correcting hypothermia? Yes No Record data, e.g., wears appropriate Reassess using initial assessment factors. clothing, house temperature at 75°F, uses electric blanket. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has identified one factor—appropriate Did evaluation show another clothing—but no others. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 150 NUTRITIONAL-METABOLIC PATTERN Infant Feeding Pattern, Ineffective RELATED FACTORS30 DEFINITION 1. Prolonged NPO status 2. Anatomic abnormality A state in which an infant demonstrates an impaired ability to suck 3. Neurologic impairment or delay or coordinate the suck-swallow response.30 4. Oral hypersensitivity 5. Prematurity NANDA TAXONOMY: DOMAIN 2—NUTRITION; CLASS 1—INGESTION RELATED CLINICAL CONCERNS NIC: DOMAIN 5—FAMILY; CLASS W— CHILDREARING CARE 1. Prematurity 2. Cerebral palsy NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 3. Thrush CLASS K—NUTRITION 4. Hydrocephalus 5. Any condition that would require major surgery immediately af- DEFINING CHARACTERISTICS30 ter birth 1. Inability to coordinate sucking, swallowing, and breathing 2. Inability to initiate or sustain an effective suck HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Breastfeeding With this diagnosis, the and breathing, then Ineffective Infant Feeding infant is able to suckle and swallow, but there is Pattern is the most appropriate diagnosis. dissatisfaction or difficulty with the breastfeeding Imbalanced Nutrition, Less Than Body process. The key difference would be based on the Requirements Certainly this diagnosis could be defining characteristics of Ineffective Breastfeeding the result of Ineffective Infant Feeding Pattern if the versus Ineffective Infant Feeding Pattern. If the feeding problem is not remedied. However, infant demonstrates problems with initiating, correction of the primary problems would prevent sustaining, or coordinating sucking, swallowing, the development of this diagnosis. EXPECTED OUTCOME TARGET DATES Will demonstrate normal ability to suck-swallow by [date]. This diagnosis would be life-threatening; therefore, progress should initially be evaluated every few hours. After the infant has begun to exhibit at least some sucking-swallowing, then the target date can be moved to every 2 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this diagnosis, Child Health and Women’s Health (Newborn) serve as the generic actions. This diag- nosis would not be used in adult health. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributory factors: A thorough assessment and monitoring serves as the critical basis � Actual physiologic sucking potential for appropriately individualizing and prioritizing a plan of health � Other objective concerns, e.g., swallowing or respiratory care. � Objective history data, e.g., prematurity or congenital anomalies � Maternal or infant reciprocity � Subjective data from the caregivers or parents • Provide anticipatory support to the infant for respiratory Airway maintenance is a basic safety precaution for this infant. difficulties that could increase the probability of aspiration. Airway and suctioning equipment are standard (see nursing actions for Risk for Aspiration). • Ascertain the most appropriate feeding protocol for the infant A realistic yet holistic approach provides a foundation for with attention to: multidisciplinary management with best likelihood for success. � Nutritional needs according to desired weight gain Specific criteria provide measurable progress parameters. (continued) Copyright © 2002 F.A. Davis Company INFANT FEEDING PATTERN, INEFFECTIVE 151 (continued) ACTIONS/INTERVENTIONS RATIONALES � Actual feeding mode, i.e., modified nipple, larger hole nipple, syringe adapted for feeding, position for feeding, or gastric tube � Health status and prognosis � Compliance factors � Socioeconomic factors � Maternal-infant concerns • Explore the feelings the caregivers or parents have related to the Often the expression of feelings reduces anxiety and may allow Ineffective Feeding Pattern. further potential alterations to be minimized by early intervention. • Strictly monitor and calculate intake, output, and caloric count Caloric intake and hydration status are indirectly and directly used on each shift, and total each 24 h. to monitor the infant’s progress in tolerance of feeding and feeding efficacy. • Weigh the infant daily or more often as indicated. Weight gain would serve as a major indicator of effective feeding and assist in assessment of hydration. • Collaborate with other health care professionals to better meet A multidisciplinary approach is most effective in level and cost of the infant’s needs. care. • Allow for appropriate time to prepare the infant for feeding, and A nonhurried, nonstressful milieu promotes the infant’s relaxation provide a calm, soothing milieu. and allows the infant to perceive feeding as a pleasant experience. • Encourage the family to participate in feeding and plans for Inclusion of the family empowers the family and augments their feeding. self-confidence and coping. • Provide teaching based on an assessment of parental knowledge Knowledge provides a means of decreasing anxiety. When based on needs and/or deficits. assessed needs, it will reflect the individualized needs and more likely meet the parent’s learning needs. • Allow for time to clarify feeding protocols, questions, and Appropriate attention to questions and concerns the parents may discharge planning. have assists in reducing anxiety, thereby allowing for learning and a greater likelihood of adherence to the therapeutic regimen. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Provide support and information to the mother and significant The basic rationale for all the nursing actions in this diagnosis is to other. Explain the infant’s inability to suck, and provide provide nutrition to the infant in the most appropriate, suggestions and options (based on etiology of sucking problem) cost-effective, and successful manner. to correct or reduce problem.49,63,64 • Describe the anatomy and physiology of sucking to the mother. Assists in decreasing anxiety, provides a base for teaching, and permits long-range planning. • Explain importance of positioning for both bottle- and Encourages proper suckling by the infant. breastfeeding.64–66 • Provide support and supervision to assist mother in encouraging infant to suck properly. • Assist the mother and family to assess appropriate intake by Ensures that the infant is getting enough nutrition and is not observing the infant for at least 6–8 wet diapers in 24 h (after becoming dehydrated.51,52,63 milk has come in). • If necessary, provide supplemental nutrition system while Pays attention to basic nutrition while also attending to problem teaching infant to suck, e.g., dropper, syringe, spoon, cup, or with sucking. supplementation device.67,68 • Refer the mother to lactation consultant or clinical nurse specialist for assistance and support in teaching the infant to suck. • Assist the mother and significant others to choose feeding Provides basic support to encourage essential nutrition. system for the infant (breast, bottle, cup, or tube) that will supply best nutrition. Psychiatric Health This diagnosis would not be used in Psychiatric Health. Gerontic Health This diagnosis is not appropriate for the gerontic patient. Home Health The nursing actions for Home Health would be the same as for Women’s Health. Copyright © 2002 F.A. Davis Company 152 NUTRITIONAL-METABOLIC PATTERN Infant Feeding Pattern, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Does the infant demonstrate normal ability to suck and swallow? Yes No Record data, e.g., has had no Reassess using initial assessment factors. problems with sucking or swallowing for past 72 hours, has gained 8 oz. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., shows no weight gain; still has problems Did evaluation show another with sucking, swallowing, and problem had arisen? Yes breathing coordination at each feeding. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company NAUSEA 153 Nausea 3. Irritation to the gastrointestinal system 4. Stimulation of neuropharmacologic mechanisms DEFINITION RELATED CLINICAL CONCERNS An unpleasant, wave-like sensation in the back of the throat, epi- gastrium, or throughout the abdomen that may or may not lead to 1. Any surgical procedure vomiting.30 2. Cancer 3. Any gastrointestinal disease NANDA TAXONOMY: DOMAIN 12—COMFORT; 4. Viruses CLASS 1—PHYSICAL COMFORT 5. Pregnancy NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; CLASS E—PHYSICAL COMFORT PROMOTION NOC: DOMAIN V—PERCEIVED HEALTH; CLASS V— SYMPTOM STATUS HAVE YOU SELECTED THE CORRECT DIAGNOSIS? DEFINING CHARACTERISTICS30 There really are no other diagnoses that 1. Usually precedes vomiting, but may be experienced after vom- could be confused with this diagnosis. iting or when vomiting does not occur 2. Accompanied by pallor, cold and clammy skin, increased sali- vation, tachycardia, gastric stasis, and diarrhea EXPECTED OUTCOME 3. Accompanied by swallowing movements affected by skeletal muscles Will self-report no nausea by [date]. 4. Reports “nausea” or “sick to stomach” TARGET DATES RELATED FACTORS30 Because uncontrolled nausea and vomiting can quickly lead to fluid 1. Chemotherapy and electrolyte imbalance, target dates should be at 24-hour inter- 2. Postsurgical anesthesia vals until the nausea is controlled. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Avoid food smells or unpleasant odors. Olfactory sense is important in the total dining experience. • Avoid greasy, fatty meals. Greasy foods promote nausea. • Consult with the patient and dietitian about food likes and Helps patient feel a part of health care. dislikes. [List foods here.] • Try small, frequent feedings. Drink fluids between meals rather Reduces the amount of food in the stomach and avoids the feeling than with meals. of fullness. • Elevate head of bed for 30 min after eating. Promotes digestion by gravity. • Teach diversion, guided imagery, and relaxation.69 Reduces stress and takes the mind off the nausea. • Place a cold washcloth over eyes and cheeks. Cools the face and diverts blood and attention away from the stomach. • Collaborate with physician about acupuncture or acupressure.70 Alternative treatments. • Administer antiemetic medications as ordered. Monitor for effects.71–76 • Provide the patient with a whiff of isopropyl alcohol.77 Diverts attention from stomach. • Consult with physician about the use of 80 percent oxygen Increased oxygen provides more oxygen-rich blood to circulate. during periods of nausea. • Encourage or assist with oral hygiene after each meal and before Cleans and lubricates the mouth. Helps the mouth feel fresh. bedtime. • Consider alternative therapies such as ginger, peppermint, or Helps calm the stomach. cinnamon. Copyright © 2002 F.A. Davis Company 154 NUTRITIONAL-METABOLIC PATTERN Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributory factors including: A thorough assessment provides the most appropriate base of data � Actual physiologic components (electrolyte imbalances, for individualized care. history of cancer, altered metabolic status, bilirubin elevations, increased intracranial pressure, gastrointestinal irritation/deviations, etc.) � Potential pharmacologic agents (chemotherapy agents, medications, or allergens) � Emotional concerns of the client and family

or significant others � Subjective data from all who have influence in care of the client • Identify the pattern of nausea, including known precedent A thorough assessment of the pattern assists in individualization of auras or sensations, triggering stimuli, correlation of stimuli to care with the intent of remaining open to ongoing priorities as well perception of nausea or suggestion of nausea, physical signs and as the identification of other nursing problems. symptoms noted, length of duration of symptoms, factors noted to ameliorate perceived nausea, and ongoing effects nausea exerts. • Develop a plan for dealing with nausea with an element of An individualized plan of care with specific needs addressed will ongoing monitoring every 1 h or more often as needed, for goal best afford successful management of nausea. of lessening of perceptions or suggested nausea if the client is unable to express sensations. � Note signs and symptoms suggestive of nausea. � Correlate signs and symptoms with other sensations, stimuli, or events. � Identify measures to alleviate perceived sensation of nausea, such as cold cloth on forehead, administration of antiemetics, or other specific antinausea medications. � Provide a therapeutic milieu to promote rest. Eliminate noxious stimuli of noise, odors, and light. Maintain room temperature at a comfortable and steady level. � Determine need for presence of the parent or significant other to provide a sense of security for the infant or child. • Collaborate with other health professionals as needed to best A multidisciplinary approach offers the most inclusive and address needs for the client and family. cost-effective approach for care. • Offer developmentally appropriate coping mechanisms to Appropriate developmental approach is critical to success in enhance the child’s sense of self-worth and likelihood of creating the best effort for self-worth of the infant or child and the cooperation. parent. Women’s Health The nursing actions for this diagnosis are the same as for Adult Health. Psychiatric Health The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health. Gerontic Health See interventions for Adult Health for common nursing interventions. In older populations, some of the following concerns may also be present. ACTIONS/INTERVENTIONS RATIONALES • Review the older adult’s medications to determine whether GI Many drugs taken by older adults, such as opioids, antidepressants, problems are noted as a side effect.25 and anticholinergics, have nausea as a side effect.78 • Determine whether the older adult is using herbs (aloe, senna, Using large amounts of herbal laxatives may cause nausea.79 cascara) to alleviate problems with constipation. • Discuss with the client, if noted, stress effects on the GI system, Stress can lead to reductions in peristalsis and digestive enzymes and assist the client with relaxation strategies as needed to and cause nausea, anorexia, abdominal distention, or vomiting.55 reduce stress. • Monitor the infusion rate of tube feeding, if present, to prevent Rapid feeding rates can produce nausea.80 rapid feeding. Copyright © 2002 F.A. Davis Company NAUSEA 155 Home Health ACTIONS/INTERVENTIONS RATIONALES • Educate the client and caregivers on how to deal with nausea: Increases the ability to manage situations quickly and � Avoid sudden changes in position. independently. Prevents episodes of nausea from external factors. � Keep environment clean and free of noxious odors. � Keep environment well ventilated; a fan or open window is often helpful. � Use relaxation or diversion. � Apply cool washcloths to the face and neck. � Avoid hot baths or hot environment. • Help the client identify foods that may precipitate episodes of Prevents future episodes. nausea. • Educate the client and caregivers in the administration of Promotes a sense of independence by the client, and facilitates prescribed antiemetics. Help the client to clearly identify obtaining appropriate prescriptions. accompanying symptoms to assist the physician in prescribing the correct type of antiemetics. • Help the client to identify prescription medications, particularly Facilitates changing prescriptions as necessary. antibiotics and opioids, that may be causing the nausea. • When the client believes that foods can be tolerated, encourage Rapidly reintroducing solid food may stimulate nausea and him or her to start with clear liquids at moderate temperatures vomiting. and progress to soft bland foods in small amounts. Copyright © 2002 F.A. Davis Company 156 NUTRITIONAL-METABOLIC PATTERN Nausea FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient self-reported any nausea? Yes No Reassess using initial assessment factors. Record data, e.g., has had no complaint of nausea for 72 h. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Is diagnosis validated? Did evaluation show another Yes No problem had developed? Record data, e.g., is still complaining of nausea at least 2 times per day. Record CONTINUE and change Yes No target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, LESS THAN BODY REQUIREMENTS 157 Nutrition, Imbalanced, Less Than 9. Misconception 10. Loss of weight with adequate food intake Body Requirements 11. Aversion to eating 12. Abdominal cramping DEFINITION 13. Poor muscle tone The state in which an individual experiences an intake of nutrients 14. Abdominal pain with or without pathology insufficient to meet metabolic needs.30 15. Lack of interest in food 16. Body weight 20 percent or more below ideal 17. Capillary fragility NANDA TAXONOMY: DOMAIN 2—NUTRITION; 18. Diarrhea and/or steatorrhea CLASS 1—INGESTION 19. Excessive loss of hair NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 20. Hyperactive bowel sounds CLASS D—NUTRITION SUPPORT 21. Lack of information; misinformation NOC: DOMAIN II—PHYSIOLOGIC HEALTH; RELATED FACTORS30 CLASS K—NUTRITION Inability to ingest or digest food or absorb nutrients as a result of DEFINING CHARACTERISTICS30 biologic, psychological, or economic factors. 1. Pale conjunctival and mucous membranes RELATED CLINICAL CONCERNS 2. Weakness of muscles required for swallowing or mastication 3. Sore, inflamed buccal cavity 1. Anorexia nervosa or bulimia 4. Satiety immediately after ingesting food 2. Cancer 5. Reported or evidence of lack of food 3. AIDS 6. Reported inadequate food intake less than RDA (recom- 4. Alzheimer’s disease mended daily allowance) 5. Anemia 7. Reported altered taste sensation 6. Ostomies 8. Perceived inability to ingest food 7. Schizophrenia, paranoid HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Oral Mucous Membrane If the oral means—seeing, smelling, or tasting—or if the mucous membranes are severely inflamed or person thinks he or she has already eaten, then the damaged, food intake could be so painful that the desire to eat may not exist. Even if the person person ceases intake to avoid the pain. Although senses hunger, the inability to feed oneself, to shop the end result might be Imbalanced Nutrition, Less for food, or to prepare food could result in less Than Body Requirements, initial intervention than adequate nutrition. would have to be aimed at handling the oral Pain If the preparation or actual eating of food mucosal problem. increases pain level, then the patient might elect to Diarrhea In this instance, the body cannot absorb avoid eating to assist in pain control. the necessary nutrients because the food material Fear, Dysfunctional Grieving, Social Isolation, passes through the gastrointestinal tract too Disturbed Body Image, Alteration in Self-Esteem, rapidly. and Spiritual Distress These diagnoses are Ineffective Tissue Perfusion Once the food has psychosocial problems that can impact nutrition. been ingested, digested, and absorbed, its Each of these may create a decreased desire to eat, components must get to the cells. If there is Altered or even if food is eaten, the person may vomit Tissue Perfusion, the nutrients may not be able to get because the stomach will not accept the food. to the cells in sufficient quantities to do any good. Additionally, if the person eats, he or she may only Self-Care Deficit, Feeding, or Disturbed Sensory pick at the food and not ingest enough to maintain Perception: Visual, Olfactory, and/or Gustatory, the body’s need for nutrients. or Ineffective Health Maintenance One of these Deficient Knowledge The person may not really diagnoses may be the primary problem. If the know how much or what kind of food is more person does not sense hunger through the usual beneficial to his or her body. EXPECTED OUTCOME TARGET DATES Will gain [number] pounds by [date]. This diagnosis reflects a long-term care problem; therefore, a target date of 5 days or more from the date of admission would be acceptable. Copyright © 2002 F.A. Davis Company 158 NUTRITIONAL-METABOLIC PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Increase food and fluid intake at each meal or feeding: Basic methods and procedures that enhance appetite. � Reduce noxious stimuli. � Open all food containers and release odors outside the patient’s room. � According to individual needs, either provide privacy for eating or provide communal dining. � Administer appropriate medications 30 min before meals (e.g., analgesics or antiemetics); record effects of medications within 30 min of administration. � If the patient requires suctioning, do so at least 15 min before Suctioning removes secretions that may cause nausea. Timing of mealtime (keep suctioning equipment available but out of activities promotes rest prior to meals. immediate eating site). • Provide a rest period of at least 30 min prior to meal. Conserves energy for feeding self and digestion. • Give oral hygiene 30 min before meals and as required. Moistens and cleanses oral mucous membranes, which promotes eating. • Assist the patient to eat, or feed the patient: � Raise the head of bed. � Help the patient wash hands. � Open carton and packages. � Cut food into small, bite-size pieces. � Provide assistive devices (e.g., large-handled spoon or fork, all-in-one utensil, or plate guard). • Offer small, frequent feedings every 2–3 h rather than just 3 Three large meals a day give a sense of fullness, and the size of meals per day. Allow the patient to assist with food choices and servings may be overwhelming to the patient. Smaller meals feeding schedules. facilitate gastric emptying, thus promoting a larger food intake overall. • Force fluid intake between meals: � Limit fluid intake at meals. � Offer wine at meals or immediately prior to meals. Alcohol stimulates gastric secretions and stimulates the appetite. • Encourage the patient to eat slowly. Allows the patient to savor the taste of food. Facilitates the digestion process. • Have the patient chew gum before meals, or have patient Stimulates salivation. visualize lemons or sour pickles. • Offer between-meal supplements. Focus on high-protein diet Provides additional caloric intake. Providing high-protein foods and liquids. and fluids helps prevent muscle-tissue loss. • Avoid gas-producing foods and carbonated beverages. Gas-producing foods promote nausea and a feeling of fullness. • Avoid very hot or very cold foods. Extremes in temperature lead to a decrease in appetite and promote irritation of oral mucous membranes. • Encourage significant others to bring special food from home. Familiar food promotes appetite and empowers the patient and family in regard to the diet. Allows an opportunity for teaching diet. • Allow rest periods of at least 30 min after feeding. Facilitates digestion and reduces stress. • Measure and total intake and output every 8 h. Total every 24 h. • Make sure intake and output is balancing at least every 72 h. Allows monitoring of renal function, and ensures that weight gain is not due to fluid retention. • Weigh daily at [state time] and in same-weight clothing. Have Assesses effectiveness of therapy and interventions. Promotes the the patient empty bladder before weighing. Teach the patient patient’s control of weight after discharge. this routine for continued weighing at home. • Encourage exercise at least twice per shift to the extent possible Stimulates appetite and prevents complications from immobility. without tiring. If exercise capacity is limited, do passive and active ROM every 4 h at [state times here] while awake. • Monitor: Allows early detection of complications, and assists in monitoring � Vital signs every 4 h while awake at [state times here] and as effectiveness of therapy. required based on measurement results � Airway, sensorium, chest sounds, bowel sounds, skin turgor, mucous membranes, bowel function, urine specific gravity, and glucose level at least once per shift (continued) Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, LESS THAN BODY REQUIREMENTS 159 (continued) ACTIONS/INTERVENTIONS RATIONALES � Laboratory

values (e.g., electrolyte levels, hematocrit, hemoglobin, blood glucose, serum albumin, and total protein) • Provide frequent positive reinforcement for: � Weight gain � Increased intake � Ignoring weight loss � Using consistent approach • Teach the patient and significant others: Provides essential information needed to prevent future episodes. � Balanced diet based on the basic food groups � Role of diet in health (e.g., healing, energy, and normal body functioning) � How to keep food diary with calorie count � Adding spices to food to improve taste and aroma � Use of exchange lists � Relaxation techniques • Refer, as necessary, to other health care providers. Provides ongoing support for long-term care. ADDITIONAL INFORMATION There will be situations in which the patient’s nutritional condition has progressed to the point that tube feedings, intravenous therapy, or total parenteral nutrition will become necessary. In addition to the nurs- ing actions for the overall nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements, the following actions should be added: Tube Feedings ACTIONS/INTERVENTIONS RATIONALES • Check placement and patency prior to each feeding. Initial Prevents aspiration, and monitors for complication of stress ulcer. placement should be checked using radiographic verification because auscultatory methods are not always accurate. Check gastric aspiration for acidic pH.81,82 • Aspirate tube prior to each feeding. Measure amount of residual Prevents overloading of stomach, and initiates assessment for from previous feeding. If 150 mL or more, delay feeding and reason stomach is not emptying. notify physician. • Check temperature of feeding before administering. Temperature Prevents abdominal cramping and reflux. should be slightly below room temperature. • Measure amount of feeding exactly. Flush tube with water Avoid overloading stomach. Flushing ensures that all feeding has immediately after feeding. entered stomach and prevents clogging of tube. • Crush medications in water or dissolve in water before giving. Permits maintenance of therapeutic regimen, and prevents Flush tube with water immediately after administering clogging of tube by medication. medication. • Keep the patient in semi-Fowler’s position for at least 30 min Prevents reflux and aspiration of feeding. following feeding. • Cleanse and lubricate nares after each feeding. Helps prevent breakdown of nasal mucosa. Promotes comfort. • Check taping of tube following each feeding. Ensures security of tube and promotes comfort. • If feeding is to be administered by gravity method (preferred), Air in stomach is uncomfortable, creates feeling of fullness, make sure all air is out of tubing. promotes nausea, and displaces space needed for nutritional feeding. Continuous Tube Feeding NOTE: In certain situations, such as severe dysphagia, clients may be placed on continuous feeding via a pump. When continuous feeding is in effect, the following additional actions should be implemented: ACTIONS/INTERVENTIONS RATIONALES • Maintain the head of the bed at a 30-degree angle at all times. Decreases the risk of aspiration, and lets gravity assist in fluid flow through stomach. • Monitor infusion rate at least every 4 h around the clock at Ensures that correct flow rate is being maintained. [times]. (continued) Copyright © 2002 F.A. Davis Company 160 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor respiratory rate, effort, and lung sounds at least every Allows monitoring for possible aspiration. 4 h around the clock at [times]. • Request medication in liquid form whenever possible. Decreases the potential blocking off of feeding tube with particulate matter. • Check for security of tube placement at least every 4 h around Guards against tube displacement. the clock at [times]. • Provide oral care every 4 h while awake at [times]. Oral care is An increase in mouth breathing leads to drying of the oral cavity especially important when the nasogastric route is used. and accumulation of debris in the mouth. Intravenous ACTIONS/INTERVENTIONS RATIONALES • Check insertion site for warmth, redness, swelling, leakage, and Basic monitoring for infiltration and venous irritation. pain at least every 4 h at [state times here]. • Check flow rate at a maximum of every hour on the Prevents fluid overload. [hour/ half-hour]. • Check for signs and symptoms of circulatory overload at least every 2 h [state times here] (e.g., headache, neck vein distention, tachycardia, increased blood pressure, or respiratory changes). • Change tubing according to agency’s stated standard or policy. Implementation of Centers for Disease Control and Prevention (CDC) guidelines; prevention of complications from tubing. Total Parenteral Nutrition ACTIONS/INTERVENTIONS RATIONALES • Do not administer without pump. The pump allows for accurate flow rate. • Change tubing and filter daily at [state time here]. Ensures proper flow of parental nutrition and avoids complications. • Change dressing every other day beginning [date]: Basic infection-preventive measures. � Use aseptic technique. � Gently cleanse area around catheter (state specifically how here—most agencies have specific policy). � Use a bacteriostatic, not antibiotic, ointment. � Apply a dry, airtight dressing. • Check insertion site for warmth, redness, swelling, leakage, and Basic monitoring for infiltration and venous irritation. pain at least every 4 h at [state times here]. Child Health NOTE: This diagnosis represents a long-term care issue. Therefore, a series of subgoals of smaller amounts of weight to be gained in a lesser period of time may be necessary. Long-term goals are still to be formulated and revised as the patient’s status demands. Also, there will undoubtedly be instances in which overlap may exist for other nursing diagnoses. Specifically, as an example, in the instance of an al- teration in nutrition related to actual failure to thrive, one must refer to appropriate role performance on the part of the mother with consideration for holistic nursing management. It would be most critical to include a few specific nursing process components to reflect the critical needs for the mother-infant dyad. ACTIONS/INTERVENTIONS RATIONALES • Feed the infant on a regular schedule that offers nutrients The stomach capacity and digestive concerns for each patient must appropriate to metabolic needs. For example, an infant of less be considered to realistically plan for weight gain over a slow, than 5 lb will eat more often, but in lesser amounts (2–3 oz steady, incremental time frame. every 2–3 h) than an infant of 15 lb (4–5 oz every 3–4 h). • Assist or feed the patient: Appropriate attention to aesthetic, physical, and emotional details � Elevate head of bed, or place the infant in infant seat, and related to feeding helps provide the optimal potential for pleasant, older infant or toddler in high chair with safety belt in place. long-lasting eating patterns. The limitation of psychological, If necessary, hold the infant. (This will be dictated in part by emotional duress cannot be overemphasized and must be the patient’s status and presence of various tubes and considered in each parent-child unit. equipment.) (continued) Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, LESS THAN BODY REQUIREMENTS 161 (continued) ACTIONS/INTERVENTIONS RATIONALES � Help the patient wash hands. For infants and toddlers, administer diaper change as needed. � Warm foods and formula as needed, and test on wrist before feeding the infant or child. � Provide aids appropriate for age and physical capacity as needed, such as two-handed cups for toddlers, favorite spoon, or Velcro strap for utensils for child with cerebral palsy. � Offer small, age-appropriate feedings with input from family members regarding the child’s preferences. � Encourage the patient to eat slowly and to chew food thoroughly. For infant, bubble before, during, and after feeding. • Provide role-modeling opportunities in a nonthreatening, Nonthreatening role-modeling and personal encouragement foster nonjudgmental manner to assist the parents in learning about compliance and lessen anxiety. feeding an infant or child. • Weigh the patient on same scale and at same time [state time Weight gain serves as a critical indicator of efficacy of treatment. here] daily. Weigh infants without clothes, older children in Maintaining consistency in weighing lessens the number of underwear. potential intervening variables that would result in an inaccurate weight. • Teach the patient and family: � Balanced diet appropriate for age using basic food groups � Role of diet in health (e.g., healing, energy, and normal body functioning). If infant is medically diagnosed as Failure to Thrive, offer appropriate emotional support and allow at least 30 min 3 times a day [state times here] for exploring dyad relationships. � How to use spices and child-oriented approach in encouraging the child to eat (e.g., peach fruit salad, with peach as a face, garnished with cherries and raisins for eyes and nose, half of a pineapple round for mouth) � Monitoring for possible food allergies, especially in toddlers with history of allergies � How to weigh self appropriately, if applicable, or for parents to weigh the child • Provide positive reinforcement as often as appropriate for the Reinforcement of desired behaviors fosters long-term compliance, parents and child, demonstrating critical behavior. thereby empowering the family with satisfaction and confidence for ultimate self-care management with minimal intervention by others. Women’s Health NOTE: Poverty and substance abuse are often associated with nutritional deficits. Remember that un- derweight women who are pregnant will exhibit a different pattern of weight gain than normal-weight women. This difference exhibits a rapid weight gain at the beginning of the first trimester of about 1 lb per week by 20 weeks. In the underweight woman, weight gain can be as much as 18 to 20 lb. Re- member to teach the parents signs and symptoms of weight loss in the neonate.43 ACTIONS/INTERVENTIONS RATIONALES • Collaborate with dietitian in planning and teaching diet: Gives baseline from which to plan better nutrition. � Emphasize high-quality calories (cottage cheese, lean meats, fish, tofu, whole grains, fruits, and vegetables). � Avoid excess intake of fats and sugar. � Assist the patient in identifying methods to keep caloric intake within the recommended limit. • Verify prepregnant weight. Assist in planning realistic diet changes within the patient’s means and according to the patient’s particular needs and habits. • Determine whether weight loss during first trimester is due to nausea and vomiting. • Check activity level against daily dietary intake. • Check for food intolerances. (continued) Copyright © 2002 F.A. Davis Company 162 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Check environmental influences: � Hot weather � Cultural practices � Pica eating � Economic situation � Ascertain economic status and ability to buy food � Monitor woman’s emotional response to the pregnancy and to additional weight gain NOTE: Dieting is never recommended during pregnancy because it deprives the mother and fetus of nutrients needed for tissue growth and because weight loss is accompanied by maternal ketosis, a direct threat to fetal well-being.5,62 • Identify additional caloric needs and sources of those calories for the nursing mother83,84: � Additional 500 cal/day above normal dietary intake is needed to produce adequate milk (depending on the individual, a total of 2500–3000 cal/day). � Additional fluids are necessary to produce adequate milk. • Collaborate with nutritionist to provide a health dietary pattern Provides basis for ensuring good nutrition, and assists in for the lactating mother. successful breastfeeding. • Monitor the mother’s energy levels and health maintenance: � Does she complain of fatigue? � Does she have sufficient energy to complete her daily activities? � Does the dietary assessment show irregular dietary intake? � Is she more than 10 percent below the ideal weight for her body stature? • For breastfeeding the newborn or neonate during the first 6 mo, teach the mother: � The major source of nourishment is human milk. � Vitamin supplements can be used as recommended by physician: (1) Vitamin D (2) Fluoride (3) If indicated, iron • The infant should be taking in approximately 420 mL daily soon Provides for good nutritional status of the newborn. after birth and building to 1200 mL daily at the end of 3 mo. • Monitor for fluid deficit at least daily: Allows early intervention for this problem � “Fussy baby,” especially if immediately after feeding � Constipation (remember breastfed babies have fewer stools than formula-fed babies) • Weight loss or slow weight gain: Closely monitor the baby, the mother, and nursing routine: � Is the baby getting empty calories (e.g., a lot of water between feedings)? � Avoid nipple confusion, which results from switching the baby from breast to bottle and vice versa many times. � Instruct the mother in “cup feeding” of nursing infant to Provides the infant with nutrition, while supporting the

ensure adequate fluid intake and avoid nipple confusion.51,52 breastfeeding mother.63 � Count number of diapers per day (should have 6–8 really wet diapers per day). � Is there intolerance to mother’s milk or bottle formula? � Is there illness or lactose intolerance? � Infrequent nursing can cause slow weight gain. Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, LESS THAN BODY REQUIREMENTS 163 Psychiatric Health NOTE: Because of long-term care requirements for these clients, target dates should be determined in weeks or months, not hours or days. ACTIONS/INTERVENTIONS RATIONALES • Do not attempt teaching or long-term goal setting with the client Starvation can affect cognitive functioning.85 until concentration has improved (symptom of starvation). • Establish contract with the client to remain on prescribed diet Provides the client with sense of control, and clearly establishes and not to perform maladaptive behavior (e.g., vomiting or use the consequences and rewards for behavior. of laxatives). State specific behavior for the client here. • Place the client on 24-h constant observation (this will be Provides consistency and structure during the stressful early discontinued when the client ends maladaptive behavior or at period of treatment. specific times that nursing staff assess are low risk). • Place the client on constant observation during meals and at Provides support for the client during stressful period. high-risk times for maladaptive behavior (such as 1 h after meals or while using the bathroom). This action will take effect when the preceding one is discontinued. • Do not allow the client to discuss weight or calories. Excessive Decreases the client’s abnormal focus on food and promotes discussion of food is also discouraged. normal eating patterns. This behavior is more indicative of starvation than an eating disorder.85 • Require the client to eat prescribed diet (all food on tray each Promotes the client’s sense of control and participation in meal except for those 3 or 4 foods the client was allowed to omit decision-making within appropriate limits. in the admission contract). List the client’s omitted food here. • Sit with the client during meals, and provide positive support Provides a positive, supportive context for the client.85 and encouragement for the feelings and concerns the client may have. • Do not threaten the client with punishment (tube feeding or IVs). • Report all maladaptive behavior to the client’s primary nurse or physician for confrontation in individual therapy sessions. • Spend [number] minutes with the client every [number] minutes to establish relationship. • Respond to queries related to fears of being required to gain too much weight with reassurance that the goal of treatment is to return the client to health and that he or she will not be allowed to become overweight. • If the client vomits, have him or her assist with the cleanup, and Provides natural consequences for behavior. require him or her to drink an equal amount of a nutritional replacement drink. • Encourage the client to attend group therapy (specific encouraging Provides support from peers and a source of honest feedback.85 behavior should be listed here, such as assisting the client to complete morning care on time or other interventions that are useful for this client). • Encourage the client’s family by [list specific encouraging Provides support for the family and an opportunity for the family behaviors for this family] to attend family therapy sessions. to work through their concerns together.85 • Assist the client with clothing selection. Clothes should not be Altered body image makes it difficult for clients to make too loose, hiding weight loss, or too tight, assisting the client to appropriate choices; honest feedback and support from the feel overweight even though appropriate weight is achieved. nursing staff makes the transition to “healthy” choices easier. • When maintenance weight is achieved, assist the client with As symptoms of starvation are resolved, the client is better able to selection of appropriate foods from hospital menu. make appropriate choices, and gradual returning of control prepares the client to accept responsibility at discharge.85 • When maintenance weight is achieved, refer to dietitian for teaching about balanced diet and home maintenance. • When maintenance weight is achieved, refer to occupational therapist for practice with menu planning, trips to grocery stores to purchase food, and meal preparation. • When maintenance weight is achieved, plan passes with the Provides further information to the client to assist in maintaining client for trips to restaurants for meals. desired weight. Provides visible reward for weight maintenance. • Allow the client to exercise [number] minutes [number] times per day while supervised (this will be altered as the client reaches maintenance weight). (continued) Copyright © 2002 F.A. Davis Company 164 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow the client to do the following exercises during the exercise period. (These are graded to the client’s physical condition. Consultation with the occupational therapist is useful.) • Allow the client [number] of [number] minute walks on Assists the client in developing realistic goals for exercise hospital grounds with a staff member each day. according to age and ability. Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those in Adult Health. Home Health NOTE: Because of long-term-care requirements for these clients, target dates should be determined in weeks or months, not hours or days. ACTIONS/INTERVENTIONS RATIONALES • Reduce associated factors, for example: Provides positive environment to promote nutritional intake. � Minimize noxious odors by using foods that require minimal cooking; or if someone else is cooking for the client, arrange for the client to be away from cooking area. � Provide social atmosphere desired by the client. � Plan medications to decrease pain and nausea around mealtime. � Plan meals away from area where treatments are performed. � Maintain oral hygiene before and after meals. Instruct the client and family in proper brushing, flossing, and use of water pick. � Encourage the client to prepare favorite foods. � Avoid foods that contribute to noxious symptoms such as gas, nausea, or GI distress. � Discourage fasting. Teach stress-reduction exercises. � Maintain exercise program as tolerated. • Teach to add high-calorie, high-protein, and high-fat items to Promotes weight gain and prevents loss of muscle mass. meal preparation activities, e.g., use milk in soups, add cheese to food, and use butter or margarine in soups and vegetables. • Teach or provide assistance to rest before meals. If the client is Provides optimal conditions to avoid overfatigue. doing the meal preparation, teach to cook large quantities and freeze several meals at a time and to seek assistance in meal preparation when fatigued. Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, LESS THAN BODY REQUIREMENTS 165 Nutrition, Imbalanced, Less Than Body Requirements FLOWCHART EVALUATION: EXPECTED OUTCOME Weigh the patient on designated date. Has the patient gained the stated number of pounds? Yes No Record data, e.g., patient now Reassess using initial assessment factors. weighs 100 lb; has gained 15 lb. Record RESOLVED (may want to use CONTINUE and let home health nurse make judgment of RESOLVED after the patient has maintained weight gain for several months). Delete diagnosis, expected outcome, target No Is diagnosis validated? date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has gained only 5 lb, states is following Did evaluation show another diet plan, can explain diet plan. problem had developed? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 166 NUTRITIONAL-METABOLIC PATTERN Nutrition, Imbalanced, More Than Body 7. Observed use of food as reward or comfort measure 8. Eating in response to internal cues other than hunger, such Requirements, Risk for and Actual as anxiety 9. Eating in response to external cues such as time of day or DEFINITIONS30 social situation 10. Dysfunctional eating patterns Risk for Imbalanced Nutrition: More Than Body Requirements B. More Than Body Requirements The state in which an individual is at risk of experiencing an intake 1. Triceps skin fold greater than 15 mm in men or 25 mm in of nutrients that exceeds metabolic needs. women Imbalanced Nutrition: More Than Body Requirements The state 2. Weight 20 percent more than ideal for height and frame in which an individual is experiencing an intake of nutrients that 3. Eating in response to external cues such as time of day or exceeds metabolic needs. social situation 4. Eating in response to internal cues other than hunger, for example, anxiety NANDA TAXONOMY: DOMAIN 2—NUTRITION; 5. Reported or observed dysfunctional eating pattern, for ex- CLASS 1—INGESTION ample, pairing food with other activities NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 6. Sedentary activity level CLASS D—NUTRITION SUPPORT 7. Concentrating food intake at end of day NOC: DOMAIN II—PHYSIOLOGIC HEALTH; RELATED FACTORS30 CLASS K—NUTRITION 1. Risk for: The risk factors also serve as the related factors. DEFINING CHARACTERISTICS30 2. More Than Body Requirements: Excessive intake in relation to metabolic needs. A. Risk for (presence of risk factors such as): 1. Reported use of solid food as major food source before 5 RELATED CLINICAL CONCERNS months of age 2. Concentrating food intake at end of day 1. Alzheimer’s disease 3. Reported or observed obesity in one or both parents 2. Morbid obesity 4. Reported or observed higher baseline weight at beginning 3. Hypothyroidism of each pregnancy 4. Disorders requiring medicating with corticosteroids 5. Rapid transition across growth percentiles in infants or children 5. Any disorder resulting in prolonged immobility 6. Pairing food with other activities HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Deficient Knowledge The patient, because of Other Possible Diagnoses Several diagnoses from cultural background, may not know the the psychosocial realm may be the underlying appropriate food groups and the nutritional value problem that has resulted in Risk for or More Than of the foods. Additionally, the cultural beliefs held Body Requirements. Powerlessness, Self-Esteem by a patient may not value thinness. Therefore, the Disturbance, Social Isolation, Disturbed Body people of a particular culture may actually Image, or Ineffective Individual Coping may also promote obesity. need to be dealt with in the patient who is at risk Ineffective Health Maintenance Because of other for or actually has Imbalanced Nutrition, More problems, the patient may not be able or willing to Than Body Requirements. modify nutritional intake even though he or she has information about good nutritional patterns. EXPECTED OUTCOME TARGET DATES Will lose [number] pounds by [date]. Because this diagnosis reflects long-term care in terms of both cause and correction, a target date of 5 days or more would not be un- reasonable. Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, MORE THAN BODY REQUIREMENTS, RISK FOR AND ACTUAL 167 NURSING ACTIONS/INTENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to identify dysfunctional eating habits, during Provides basic information needed to plan changes in first day of hospitalization, by: dysfunctional habits to begin weight-loss program. � Reviewing 1 week’s dietary intake � Associating times of eating and types of food with corresponding events, e.g., in response to internal cues or in response to external cues � Reviewing 1 week’s exercise pattern • Check activity level against daily dietary intake. • Discuss with the patient potential or real motivation for desiring Assists in understanding the patient’s rewards for goals, and to lose weight at this time. assists in establishment of goals and rewards. • Discuss with the patient past attempts at weight loss and factors Provides increased individualization and continuity of care, which that contributed to their success or failure. facilitates the development of a therapeutic relationship.86 • Limit the patient’s intake to number of calories recommended Reduces calories to promote weight loss yet maintain body’s by physician and/or nutritionist. nutritional status. • Weigh the patient daily at [state time]. Teach the patient to Provides a visible means of ascertaining weight-loss progress. weigh self at the same time each morning in same clothing. Help the patient to establish a graphic to allow visualization of progress, e.g., bar chart, chart with gold star for each weight-loss day. • Provide good skin care and monitor skin daily, especially skin These areas are especially prone to impaired skin integrity because folds and areas where skin meets skin. of the collection of moisture and

continuous friction. • Measure total intake and output every 8 h. Encourage intake of Ensures renal functioning and maintenance of fluid balance. A low-calorie, caffeine-free drinks. significant amount of weight loss in the first few days is due to fluid excretion. Low-calorie, caffeine-free drinks help offset “hunger pains.” • Collaborate with physical therapist in establishing an exercise Exercise burns calories and tones muscles. program. • Assist the patient in selecting an exercise program by providing Assists in narrowing the range between calories consumed and the patient with a broad range of options, and have the client calories burned. Facilitates development of adaptive coping select one he or she will enjoy. behaviors. • Develop a schedule and goals for implementing the exercise Promotes patient self-esteem when goals can be accomplished, and plan. (Set goals that are achievable, usually this is 50 percent of provides motivation for continued efforts. what the patient estimates is achievable.) Develop a reward schedule for achievement of exercise goals, and record this plan here. • Teach stress reduction techniques, and have the patient Helps alleviate eating associated with stress. Facilitates the return-demonstrate for at least 30 min at least twice a day at patient’s development of alternative coping behaviors. [times], e.g., progressive relaxation, scheduled quiet time, or time management. • Assist the patient to establish a food diary, during first day of Helps the patient to identify real intake and to identify behavioral hospitalization, which should be maintained until weight has and emotional antecedents to dysfunctional eating behavior.35,36,87 stabilized within normal limits: � What eating: Caloric intake � Where eating: All actual sites � When eating: Time of day, length of time spent eating, or circumstances leading to deciding to eat � Activity during this time � Feelings and emotions before, during, and after eating � Provide space for listing of all physical activity, e.g., walked 11⁄2 blocks from car to office. • Review diary with the patient on a daily basis, and list those factors that will assist with a weight-loss plan and those that will hinder a weight-loss plan. (continued) Copyright © 2002 F.A. Davis Company 168 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach the patient principles of balanced diet, or refer to dietitian Provides basic knowledge needed to control weight at home. for instructions, at least 3 days prior to discharge: Promotes self-care. Promotes the patient’s perception of control � Food guide pyramid � Recommended daily allowances � Weighing and measuring foods � Exchange lists • Instruct the patient to grocery shop from a list and soon after eating. • Discuss with the patient those foods that provide the greatest risk of decreasing self-control, and develop a plan for eliminating them from the diet. • Use visual aids to increase effectiveness of diet teaching. • Schedule adequate time for teaching. Convey positive attitude, and reinforce information about food groups. • Spend 30 min at least twice a day at [times] with the patient Promotes a positive orientation and sense of control for the reviewing the benefits of weight loss and the progress made to patient.86 this point. Do not focus on the concept of loss when talking with the patient; use terms such as reduction and gains in self-concept to provide positive ideas. • Discuss with the patient other life achievements and strategies Promotes positive orientation and focuses on strengths the patient that assisted with attaining these achievements. Focus on the already possesses. concept of perseverance in attaining the achievement, or discuss with the patient the last long trip taken and apply the concept of persevering and planning that allowed the trip to be taken. Relate the ideas of persevering and planning to the task of weight loss. • Present the concept of approaching goals one day at a time Promotes positive orientation by setting readily achievable goals. rather than attempting or reflecting on all of the task. • Review pros and cons of alternate weight-loss options with the Promotes safety in weight-loss plan. Avoids serious complications patient: such as heart failure due to questionable weight-loss ideas. � Fad diets � Diet pills � Liquid diet preparations � Surgery � Diuretics � Laxatives � Bingeing and purging • Demonstrate adaptations in eating that could promote weight Assists in behavior modification needed to lose weight. loss: � Smaller plate � One-half of usual serving � No second servings � Laying fork down between bites � Chewing each bite at least X number of times • Teach alternative food preparation habits that will reduce Reduction of fat in meal preparation assists in calorie reduction calories while increasing nutritional content of diet: and weight loss. Often excess food is consumed for water content � Boil or broil instead of frying food. when water would satisfy the need. Facilitates development of � Use nonstick spray for pans instead of butter, margarine, adaptive eating behaviors. or fat. � Use fruits and vegetables. � Increase use of fish or poultry over beef or pork. � Drink water or herbal tea for thirst; do not confuse thirst for hunger. � Reduce or eliminate fat and sugar from recipes. � Use fresh ingredients whenever possible for increased flavor. � Use fresh fruit canned in its own juice for sweetening instead of sugar. � Use plain yogurt or blended and seasoned tofu as substitutes for sour cream. • Provide the patient with a calorie list of fast-food items, and Promotes the patient’s perception of control. Provides planned plan for maintaining desired goals by: strategies for coping before entering potentially difficult situations. � Developing a list of those fast-food items that provide the best food value for the calories. (continued) Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, MORE THAN BODY REQUIREMENTS, RISK FOR AND ACTUAL 169 (continued) ACTIONS/INTERVENTIONS RATIONALES � Assisting the patient with developing recipes to use at home that are calorie-wise and easily prepared to decrease the temptation to use fast food. � Developing a list of those restaurants that provide options for reducing calorie intake, such as those with salad bars or the option to eliminate certain items from a serving, e.g., high-calorie condiments. • Have the patient design own weight-loss plan at least 3 days Allows the patient to assume control for long-term therapy. The prior to discharge to allow practice and revision as necessary: more the patient is involved in planning care, the higher the � Caloric intake probability for compliance. � Activity � Behavioral or lifestyle changes, i.e., those behaviors that will replace factor that inhibits weight-loss • Encourage the patient to increase activity by: � Walking up stairs instead of riding elevators at work � Taking walks in the evening before retiring • Consult with the family and visitors regarding importance of the Involves others in supporting the patient in weight-loss effort. patient’s adhering to diet. Caution against bringing food, etc. from home. • Discuss with the patient and significant others the necessary alterations in eating behavior, and develop a list of ways the significant others can be supportive of these alterations. • Use appropriate behavior modification techniques to reinforce Reinforcement supports change. teaching. Refer the patient and family to psychiatric nurse practitioner for appropriate techniques to use at home as well as assistance with guilt, anxiety, etc. over being obese. • Plan for times when the patient will indulge in high-calorie Promotes the patient’s perception of control. meals or snacks, such as holidays, by developing an attitude of nonfailure and regained control or coping. Time may be planned for the patient to “break” the diet. • If bingeing has been a problem and other techniques have not The patient’s not following through with the planned binge will effectively eliminated it, then assist the patient in planning the demonstrate his or her control over binges, and his or her strength next binge to the final detail. can be promoted. The patient following through with the planned binge can also demonstrate control; the patient regains power and can then proceed to schedule and plan binges, altering the frequency and amount consumed gradually. Either option should be positively received by the nurse with appropriate follow-up to promote the patient’s positive orientation.86,87 • Suggest that the patient contract with a significant other or home Provides added reinforcement and support for continued weight health nurse prior to discharge. loss. • Develop a list of rewards for positive changes. These rewards Many patients will have difficulty identifying nonfood rewards, should be ones that the patient will give himself or herself or and a great deal of support may be needed. Rewards should that can be given by the health care team or patient support initially be scheduled on a daily basis for successful achievement system and should not be related to food. The patient’s reward of behavior related to weight loss and can then be gradually schedule should be listed here. expanded to weekly or monthly rewards that promote the patient’s self-esteem and provide motivation for continued efforts. • Instruct the patient to postpone desires to eat between meals by Provides the patient time to substitute positive coping behaviors doing 5 min of slow deep breathing and reviewing 3 of the for dysfunctional eating behavior.34 identified positive motivating factors for weight loss for this patient. If the desire to eat remains, have the patient drink a glass of water or cup of herb tea and spend 10 min engaged in an activity such as writing a letter, working on a hobby, reading, sewing, or playing with children or spouse or significant other—anything but watching television (this activity generally contains too many food cues). • Refer to community resources at least 3 days prior to discharge Provides long-range support for continued success with weight from hospital. loss. Child Health Orders are the same as for the adult. Make actions specific to the child according to the child’s develop- mental level. Copyright © 2002 F.A. Davis Company 170 NUTRITIONAL-METABOLIC PATTERN Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Verify the prepregnancy weight. Provides basis for planning diet with the patient. • Obtain a 24-h diet history. Ask the patient to select a typical day. • Calculate the woman’s calorie and protein intake. • Rule out excessive edema and hypertension. Measure ankles and abdominal girth and record. Remeasure each day. Measure blood pressure every 4 h while awake at [state times here]. • Encourage the client to increase her activity by: Assists in maintaining desired weight gain; improves muscle tone � Joining exercise groups for pregnancy (usually found in and circulation. childbirth classes in community) � Joining swim exercise groups for pregnancy (usually found at YWCAs or community centers) • Refer to appropriate support groups for assistance in exercise programs for the pregnant woman (e.g., physical therapist, local groups that have swimming classes for pregnant women, and childbirth classes). • If recommended intake is 2400 cal/day but 24-h diet recall Basic measures and teaching factors to assist in weight control. reveals a higher caloric intake: � Recommend reduction of fat in diet (e.g., decrease amount of cooking oil used, use less salad dressing and margarine, cut excess fat off meat, and take skin off chicken before preparing). � Monitor size of food portions. � Stress appetite control with high-quality sources of energy and protein. • Assist mothers with cultural or economic restrictions to introduce more variety into their diets. • Stress that weight gain is the only way the fetus can be supplied with nourishment. • Point out that added body fat will be burned and will provide necessary energy during lactation (breastfeeding). • Assist pregnant adolescents within 3 yr of menarche to plan Diet has to be planned to meet the growth needs of the adolescent diets that have needed additional nutrients. as well as those of the fetus. • Discourage any attempts at weight reduction or dieting. NOTE: Dieting is never recommended during pregnancy because it deprives the mother and the fetus of nutrients needed for tissue growth and because weight loss is accompanied by maternal ketosis, a direct threat to fetal well-being.62 Additional Information A satisfactory pattern of weight gain for the average woman is5: 10 weeks of gestation 650 g (approximately 1.5 lb) 20 weeks of gestation 4000 g (approximately 9.0 lb) 30 weeks of gestation 8500 g (approximately 19.0 lb) 40 weeks of gestation 12,500 g (approximately 27.5 lb) Over

the course of the pregnancy, a total weight gain of 25 to 35 lb is recommended for both nonobese and obese pregnant women. During the second and third trimesters, a gain of about 1 lb/wk is consid- ered desirable. Psychiatric Health Nursing actions for the Psychiatric Health client with this diagnosis are the same as those actions in Adult Health. Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those actions in Adult Health and Home Health. Copyright © 2002 F.A. Davis Company NUTRITION, IMBALANCED, MORE THAN BODY REQUIREMENTS, RISK FOR AND ACTUAL 171 Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client in identifying lifestyle changes that may be Knowledge and support provide motivation for change and required: increase the potential for positive outcomes. � Regular exercise at least 3 times per week, which includes stretching and flexibility exercises and aerobic activity (20 min) at target training rate. � Nutritional habits should include decreasing fat and simple carbohydrates and increasing complex carbohydrates. • Assist the client and family in identifying cues other than focus Excess focus on the weight as measured by the scale and on calorie on weight and calories, such as feeling of well-being, percentage counting may increase the probability of failure and encourage the of body fat, increased exercise endurance, and better-fitting pattern of repeated weight loss followed by weight gain. This clothes. pattern results in increased percentage of body fat. • Have the client and family design personalized plan: A personalized plan improves the probability of adherence to the � Menu planning plan. � Decreased fats and simple carbohydrates and increased complex carbohydrates � Regular, balanced exercise � Lifestyle changes Copyright © 2002 F.A. Davis Company 172 NUTRITIONAL-METABOLIC PATTERN Nutrition, Imbalanced, More Than Body Requirements, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient lost the designated number of pounds? Yes No Record data, e.g., has lost 5 lb. Reassess using initial assessment factors. Record CONTINUE until patient has lost down to desired weight and has maintained loss. Judgment of RESOLVED can probably be made only by home health nurse. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., weight remains the same as on admission. Record Did evaluation show another CONTINUE and change target problem had arisen? Yes date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SWALLOWING, IMPAIRED 173 Swallowing, Impaired h. Nasal reflux i. Long meals with little consumption DEFINITION j. Coughing, choking, or gagging before a swallow k. Abnormality in oral phase of swallow study Abnormal functioning of the swallowing mechanism associated l. Piecemeal deglutition with deficits in oral, pharyngeal, or esophageal structure or m. Lack of chewing function.30 n. Pooling in lateral sulci o. Sialorrhea or drooling NANDA TAXONOMY: DOMAIN 2—NUTRITION; p. Inability to clear oral cavity CLASS 1—INGESTION RELATED FACTORS30 NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; CLASS D—NUTRITION SUPPORT 1. Congenital deficits a. Upper airway anomalies NOC: DOMAIN II—PHYSIOLOGIC HEALTH; b. Failure to thrive or protein energy malnutrition CLASS K—NUTRITION c. Conditions with significant hypotonia d. Respiratory diseases DEFINING CHARACTERISTICS30 e. History of tube feeding f. Behavioral feeding problems g. Self-injurious behavior 1. Pharyngeal phase impairment h. Neuromuscular impairment (for example, decreased or absent a. Altered head position gag reflex, decreased strength or excursion of muscles involved b. Inadequate laryngeal elevation in mastication, perceptual impairment, facial paralysis) c. Food refusal i. Mechanical obstruction (for example, edema, tracheostomy d. Unexplained fevers tube, tumor) e. Delayed swallowing j. Congenital heart disease f. Recurrent pulmonary infections k. Cranial nerve involvement g. Gurgly voice quality 2. Neurologic problems h. Nasal reflux a. Upper airway anomalies i. Choking, coughing, or gagging b. Laryngeal abnormalities j. Multiple swallowing c. Achalasia k. Abnormality in pharyngeal phase by swallowing study d. Gastroesophageal reflux disease 2. Esophageal phase impairment e. Acquired anatomic defects a. Heartburn or epigastric pain f. Cerebral palsy b. Acidic-smelling breath g. Internal trauma c. Unexplained irritability surrounding mealtime h. Tracheal, laryngeal, esophageal defects d. Vomitus on pillow i. Traumatic head injury e. Repetitive swallowing or ruminating j. Developmental delay f. Regurgitation of gastric contents or wet burps k. External trauma g. Bruxism l. Nasal or nasopharyngeal cavity defects h. Nighttime coughing or awakening m. Oral cavity or oropharyngeal abnormalities i. Observed evidence of difficulty in swallowing (e.g., stasis of n. Premature infants food in oral cavity, coughing, or choking) j. Hyperextension of head, arching during or after meals k. Abnormality in esophageal phase by swallow study RELATED CLINICAL CONCERNS l. Odynophagia 1. Cerebrovascular accident m. Food refusal or volume limiting 2. Any neuromuscular diagnosis, for example, myasthenia n. Complaints of something stuck gravis, muscular dystrophy, cerebral palsy, Parkinson’s disease, o. Hematemesis Alzheimer’s disease, poliomyelitis p. Vomiting 3. Hyperthyroidism 3. Oral phase impairment 4. Any medical diagnosis related to decreased level of conscious- a. Lack of tongue action to form bolus ness, for example, seizures, concussions, increased intracranial b. Weak suck resulting in inefficient nippling pressure c. Incomplete lip closure 5. Tracheoesophageal problems, for example, fistula, tumor, edema, d. Food pushed out of mouth or presence of tracheostomy tube e. Slow bolus formation 6. Anxiety f. Food falls from mouth g. Premature entry of bolus Copyright © 2002 F.A. Davis Company 174 NUTRITIONAL-METABOLIC PATTERN HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Oral Mucous Membrane Impaired to pass into the stomach without crowing, Swallowing implies that there is a mechanical or coughing, or choking, the appropriate nursing physiologic obstruction between the oropharynx diagnosis is not Impaired Swallowing. and the esophagus. An Impaired Oral Mucous Imbalanced Nutrition, Less Than Body Membrane indicates that only the oral cavity is Requirements Certainly Imbalanced Nutrition, involved. Structures below the oral cavity, per se, Less Than Body Requirements would be a are not affected. If liquids or solids are able to pass consideration and probably a secondary problem through the oral cavity, even though pain or to Impaired Swallowing. Choosing between the difficulty might be present, there will be nothing two diagnoses would be based on the related obstructing its passage through the esophagus to factors, with Impaired Swallowing taking priority the stomach. Therefore, if solids or liquids are able over the Impaired Nutrition initially. EXPECTED OUTCOME TARGET DATES Will be able to freely swallow [solids/liquids] by [date]. Because Impaired Swallowing can be life-threatening, the patient should be checked for progress daily. After the condition has im- proved, progress could be checked at 3-day intervals. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for lesions or infectious processes of the mouth and Lesions or ulcers in the mouth promote difficulty in swallowing. oropharynx at least once per shift. • Test, prior to every offering of food, fluid, etc., for presence of To prevent choking and aspiration. gag reflex. • Prior to offering food or fluids, test swallowing capacity with Provides equipment needed in case of aspiration or respiratory clear, sterile water only. Have suctioning equipment and obstruction emergency. tracheostomy tray on standby in the patient’s room. • Support hydration and caloric intake. Collaborate with Maintains fluid and electrolytes even though the patient may not physician regarding the need for IVs, hyperalimentation, etc. be able to swallow. • Maintain appropriate upright position during feeding. Gravity assists in facilitation of swallowing. • Warm fluids before offering to the patient. Warm fluids assist swallowing through mild relaxation of esophageal muscles. • Stay with the patient while he or she tries to eat. Basic safety measure for the patient who has difficulty in swallowing. • Be supportive to the patient during swallowing efforts. Swallowing difficulty is very frustrating for the patient. • Consult with nutritionist about the patient’s preferred food list and about enhancing the nutritional value of those foods that are easier for the patient to swallow (e.g., adding vitamins to warm liquids). • Provide for rest periods before and after eating. Coughing episodes are frequent with impaired swallowing, and coughing is very tiring. • Measure and document intake and output each shift. Total Basic monitoring of the patient’s condition. Permits a consistent each 24 h. and more accurate comparison. • Weigh the patient each day at the same time [note time here] and in same-weight clothing. • Advance diet as tolerated. • Teach the patient who has had supraglottic surgery an alternate Facilitates active swallowing and support for the patient as he or method of swallowing: she begins to adapt to impaired swallowing. � Have the patient clear his or her throat by coughing and expectorating. If the patient is unable to expectorate, suction the secretions. � Have the patient inhale as the food is put in the mouth. (continued) Copyright © 2002 F.A. Davis Company SWALLOWING, IMPAIRED 175 (continued) ACTIONS/INTERVENTIONS RATIONALES � Have the patient then perform a Valsalva maneuver as he or she is swallowing. � Have the patient cough, swallow again, and exhale deeply. � Start with soft, nonacidic, noncrumbly foods rather than liquids. Liquids are more difficult to control. � Provide privacy for the patient as he or she learns alternate swallowing. � Teach at least one other family member or significant other how to support the patient in alternate swallowing, suctioning, Heimlich maneuver, etc. • Refer as needed to other health care team members. Collaboration supports a holistic approach to patient care. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributory factors, especially palate formation, A thorough assessment will best identify those patients who have possible tracheoesophageal fistula, or other congenital anomalies. greater-than-usual likelihood of swallowing difficulties due to structural, acquired, or circumstantial conditions. • Maintain the infant in upright position after feedings for at An upright position favors, by gravity, the digestion and absorption least 11⁄2 h. of nutrients, thereby decreasing the likelihood of reflux and resultant potential for choking. • Address anticipatory safety needs for possible choking: Usual anticipatory airway management is appropriate in long-term � Have appropriate suctioning equipment available. patient management while education and teaching concerns can � Teach the parents CPR. be addressed in a supportive environment, thereby reducing � Provide parenting support for CPR and suctioning. anxiety in event of cardiopulmonary arrest secondary to impaired � Assist the family to identify ways to cope with swallowing swallowing. disorder, e.g., the need for extra help in feeding. • Administer medications as ordered. Avoid powder or pill forms. Pills or powders may increase the likelihood of impaired Use elixirs or mix as needed. swallowing in young children and infants. Appropriate mixing with fruit syrups or using manufacturer’s elixir or suspension form of the drug lessens the likelihood of impaired swallowing. Women’s Health The nursing actions for a woman with the nursing diagnosis of Impaired Swallowing are the same as those for Adult Health. Psychiatric Health NOTE: The following nursing actions are specific considerations for the mental health client who has Impaired Swallowing that is caused or increased by anxiety. Refer to Psychiatric Health nursing actions for the diagnosis of Anxiety for interventions related to decreasing and resolving the client’s anxiety. If swallowing problems are related to an eating disorder, refer to Psychiatric Health nursing actions for Imbalanced Nutrition, Less Than Body Requirements, for additional nursing actions. ACTIONS/INTERVENTIONS RATIONALES • Provide a quiet, relaxed environment during meals by discussing Promotes the client’s control and facilitates relaxation response, with the client the situations that increase anxiety and excluding thus inhibiting the sympathetic nervous system response.29,86 those factors from the situation. Provide things such as favorite music and friends or family that increase relaxation. (Note information provided by the client here, especially those things that need to be provided by the nursing staff.) • Provide medications in liquid or injectable form. (Note any Liquids are easier to swallow than tablets. Providing medications by special preference the client may have in presentation of injection would prevent any swallowing problems. medications here.) • Teach the client deep muscle relaxation. (Refer to the Psychiatric Health nursing actions for Anxiety for actions Promotes client control and inhibits the sympathetic nervous related to decreasing anxiety.) system response. (continued) Copyright © 2002 F.A. Davis Company 176 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client foods that are the easiest and the most Promotes client control. difficult to swallow. Note information from this discussion here. (Note time

and person responsible for this discussion here.) • Plan the client’s most nutritious meals for the time of day he or she is most relaxed, and note that time here. • Provide the client with high-energy snacks several times during Provides additional calories in frequent small amounts. the day. (Note snacks preferred by the client and time they are to be offered here.) • Assign primary nurse to sit with the client 30 min (this can be Provides increased individualization and continuity of care, increased to an hour as the client tolerates interaction time facilitating the development of a therapeutic relationship. The better) 2 times a day to discuss concerns related to swallowing. nursing process requires that a trusting and functional (This can be included in the time described under the nursing relationship exist between nurse and client.86 actions for Anxiety.) As the nurse-client relationship moves to a working phase, discussion can include those factors that precipitated the client’s focus on swallowing. These factors could be a trauma directly related to swallowing, such as an attack in which the client was choked or in which oral sex was forced. • Teach the client and client’s support system nutrition factors Promotes long-term support for assistance with problem. that will improve swallowing and maintain adequate nutrition. Note here the names of those persons the client would like included in this teaching. Note time arranged and person responsible for this teaching here. Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those for Adult Health and Psychiatric Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach measures to decrease or eliminate Impaired Swallowing: Prevents or diminishes problems. Promotes self-care and provides � Principles of oral hygiene database for early intervention. � Small pieces of food or pureed food as necessary � Aspiration precautions, e.g., eat and drink sitting up, do not force-feed or fill mouth too full, and CPR � Proper nutrition and hydration � Use of adaptive equipment as required • Teach to monitor for factors contributing to Impaired Swallowing, e.g., fatigue, obstruction, neuromuscular impairment, or irritated oropharyngeal cavity, on at least a daily basis. • Involve the client and family in planning, implementing, and Goal setting and communication promote positive outcomes. promoting reduction or elimination of Impaired Swallowing by establishing regular family conferences to provide for mutual goal setting and to improve communication. . • Assist the client and family in lifestyle changes that may be Knowledge and support provide motivation for change and required: increase the potential for a positive outcome. � The client may need to be fed. � Mealtimes should be quiet, uninterrupted, and at consistent times on a daily basis. � The client may require special diet and special utensils. Copyright © 2002 F.A. Davis Company SWALLOWING, IMPAIRED 177 Swallowing, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient swallow (fluid, food) without any difficulty? Yes No Record data, e.g., has been Reassess using initial assessment factors. swallowing fluids without difficulty for 3 days; no coughing or choking. Record RESOLVED (may want to use CONTINUE until the patient can swallow food with no difficulty). Delete nursing No Is diagnosis validated? diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated “swallowing more easily”; Did evaluation show another still has episodes of coughing. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 178 NUTRITIONAL-METABOLIC PATTERN Thermoregulation, Ineffective 5. Hypertension 6. Increased respiratory rate DEFINITION 7. Pallor (moderate) 8. Piloerection The state in which the individual’s temperature fluctuates between 9. Reduction in body temperature below normal range hypothermia and hyperthermia.30 10. Seizures or convulsions 11. Shivering (mild) NANDA TAXONOMY: DOMAIN 11—SAFETY/ 12. Slow capillary refill PROTECTION; CLASS 6—THERMOREGULATION 13. Tachycardia 14. Warm to touch NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; CLASS M—THERMOREGULATION RELATED FACTORS30 NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 1. Aging CLASS I—METABOLIC REGULATION 2. Fluctuating environmental temperature 3. Trauma or illness DEFINING CHARACTERISTICS30 4. Immaturity 1. Fluctuations in body temperature above or below the normal RELATED CLINICAL CONCERNS range 2. Cool skin 1. Any infection 3. Cyanotic nail beds 2. Any surgery 4. Flushed skin 3. Septicemia HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Hyperthermia Hyperthermia means that a person diagnosis is Hypothermia, not Ineffective maintains a body temperature greater than what is Thermoregulation. normal for himself or herself. In Ineffective Risk for Imbalanced Body Temperature With this Thermoregulation, the client’s temperature is diagnosis, the patient has a potential inability to changing between Hyperthermia and regulate heat production and heat dissipation Hypothermia. If the temperature measurement is within a normal range. The key point to remember remaining above normal, the correct diagnosis is is that a temperature abnormality does not exist Hyperthermia, not Ineffective Thermoregulation. yet, but the risk factors present indicate such a Hypothermia Hypothermia means that a person problem could develop. If the temperature maintains a body temperature below what is measurements are fluctuating between normal for himself or herself. If the temperature is hypothermia and hyperthermia, the correct consistently remaining below normal, the correct diagnosis is Ineffective Thermoregulation. EXPECTED OUTCOME TARGET DATES Will maintain a body temperature between 97 and 99F by [date]. Initial target dates will be stated in terms of hours. After stabiliza- tion, an appropriate target date would be 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor vital signs at least every hour on the [hour/half-hour]. Monitors basic trends in temperature fluctuations. Permits early recognition of ineffective thermoregulation. • Maintain room temperature at all times at 72F. Provide warmth Offsets environmental impact on thermoregulation or cooling as needed to maintain temperature in desired range; avoid drafts and chilling for the patient. • Reduce stress for the patient. Provide quiet, nonstimulating Assists body to maintain homeostasis. Stress could contribute to environment. problems with thermoregulation as a result of increased basal metabolic rate. (continued) Copyright © 2002 F.A. Davis Company THERMOREGULATION, INEFFECTIVE 179 (continued) ACTIONS/INTERVENTIONS RATIONALES • If the patient is hypothermic, see nursing actions for Thermoregulation problems may vary from hypothermia to Hypothermia on page 145. hyperthermia. • If the patient is hyperthermic, see nursing actions for Hyperthermia on page 140. • Make referrals for appropriate follow-up before dismissal from Provides long-range, cost-effective support. hospital. Child Health ACTIONS/INTERVENTIONS RATIONALES • Protect the child from excessive chilling during bathing or Evaporation and significant change of temperature for even short procedures. periods of time contribute to heat loss for the young child or infant, especially during illness. • Assist in answering the parent’s or child’s question regarding Appropriate teaching fosters compliance and reduces anxiety. temperature-monitoring procedures or administration of medications. • Assist the parents in dealing with anxiety in times of unknown Because the emphasis on monitoring and treating altered causes or prognosis by allowing 30 min per shift for venting thermoregulation is so great, it can be easy to overlook the parents anxiety. [State times here.] Interview the parents specifically to and their concerns. Specific attention must be given to ascertain anxiety. ascertaining how the patient and family are feeling about all the many concerns generated. • Involve the parents and family in the child’s care whenever Parental involvement fosters empowerment and regaining of appropriate, especially for comforting the child. self-care, thereby reestablishing the likelihood for effective family coping. Women’s Health This nursing diagnosis will pertain to women the same as it would for any other adult. The reader is re- ferred to the Adult Health and Home Health nursing actions for this diagnosis. Psychiatric Health The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health. Gerontic Health Nursing actions for the gerontic patient with this diagnosis are the same as those actions in Adult Health and Home Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to Ineffective Thermoregulation Allows early recognition and early implementation of therapy. (illness, trauma, immaturity, aging, or fluctuating environmental temperature). • Involve the client and family in planning, implementing, and Personal involvement and input increases likelihood of promoting reduction or elimination of Ineffective maintenance of plan. Thermoregulation. • Teach the client and family early signs and symptoms of Ineffective Thermoregulation (see Hyperthermia and Hypothermia). • Teach the client and family measures to decrease or eliminate Ineffective Thermoregulation (see Hyperthermia and Hypothermia). • Assist the client and family to identify lifestyle changes that may Provides basic information and planning to successfully manage be required (see Hyperthermia and Hypothermia). condition at home. Copyright © 2002 F.A. Davis Company 180 NUTRITIONAL-METABOLIC PATTERN Thermoregulation, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient maintaining a body temperature between 97 and 99°F? Yes No Record data, e.g., oral temperature Reassess using initial assessment factors. has remained between 97 and 99°F for past 5 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., oral temperature continues to Did evaluation show another vacillate between 96 and 100°F. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company TISSUE INTEGRITY, IMPAIRED 181 Tissue Integrity, Impaired 4. Smooth, atrophic, sensitive tongue 5. Geographic tongue DEFINITIONS30 6. Mucosal denudation 7. Presence of pathogens (per culture) Impaired Tissue Integrity A state in which an individual experi- 8. Difficult speech (dysarthria) ences damage to mucous membrane, corneal, integumentary, or 9. Self-report of bad taste subcutaneous tissue. 10. Gingival or mucosal pallor 11. Oral pain or discomfort Risk for Impaired Skin Integrity A state in which the individual’s 12. Xerostomia (dry mouth) skin is at risk of being adversely altered. 13. Vesicles, nodules, or papules Impaired Skin Integrity A state in which the individual has al- 14. White patches or plaques, spongy patches, or white curd- tered epidermis and/or dermis. like exudate 15. Oral lesions, lacerations, or ulcers Impaired Oral Mucous Membrane Disruptions of the lips and 16. Halitosis soft tissue of the oral cavity. 17. Edema (gingival or mucosal) 18. Hyperemia (“beefy-red”) NANDA TAXONOMY: DOMAIN 11—SAFETY/ 19. Desquamation PROTECTION; CLASS 2—PHYSICAL INJURY 20. Coated tongue 21. Stomatitis NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 22. Self-report of difficulty eating and/or swallowing CLASS F—SELF-CARE FACILITATION 23. Self-report of diminished or absent taste NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 24. Bleeding CLASS L—TISSUE INTEGRITY 25. Macroplasia 26. Gingival hyperplasia DEFINING CHARACTERISTICS30 27. Fissures, cheilitis 28. Red or bluish masses, for example, hemangioma A. Impaired Tissue Integrity 1. Damaged or destroyed tissue (cornea, mucous membrane, RELATED FACTORS30 integumentary, or subcutaneous) B. Risk for Impaired Skin Integrity* A. Impaired Tissue Integrity 1. External 1. Mechanical (pressure, shear, and friction) a. Radiation 2. Radiation (including therapeutic radiation) b. Physical immobilization 3. Nutritional deficit or excess c. Mechanical factors (shearing forces, pressure, restraint) 4. Thermal (temperature extremes) d. Hypothermia or hyperthermia 5. Knowledge deficit e. Humidity 6. Irritants f. Chemical substance 7. Chemical (including body excretions, secretions, and g. Excretions or secretions medications) h. Moisture 8. Impaired physical mobility i. Extremes of age 9. Altered circulation 2. Internal 10. Fluid deficit or excess a. Medication B. Risk for Impaired Skin Integrity b. Skeletal prominence The risk factors also serve as the related factors. c. Immunologic factors C. Impaired Skin Integrity d. Developmental factors 1. External e. Altered sensation a. Hyperthermia or hypothermia f. Altered pigmentation b. Chemical substance g. Altered metabolic state c. Humidity h. Altered circulation d. Mechanical factors (shearing forces, pressure, restraint) i. Alterations in skin turgor (change in elasticity) e. Physical immobilization j. Alterations in nutritional state (obesity, emaciation) f. Radiation k. Psychogenic g. Extremes of age C. Impaired Skin Integrity h. Moisture 1. Invasion of body structures i. Medication 2. Destruction of skin layers (dermis) 2. Internal 3. Disruption of skin surfaces (epidermis) a. Altered metabolic state D. Impaired Oral Mucous Membrane b. Skeletal prominence 1. Purulent drainage or exudates c. Immunologic deficit 2. Gingival recession with pockets deeper than 4 mm d. Developmental factors 3. Enlarged tonsils beyond what is developmentally appro- e. Altered sensation priate f. Alterations in nutritional state (obesity, emaciation) g.

Altered pigmentation h. Altered circulation *Risk should be determined by the use of a risk assessment tool (for ex- i. Alterations in skin turgor (change in elasticity) ample, Braden Scale). j. Altered fluid status D. Impaired Oral Mucous Membrane Copyright © 2002 F.A. Davis Company 182 NUTRITIONAL-METABOLIC PATTERN 1. Chemotherapy 17. Mechanical (ill-fitting dentures, braces, tubes [endotra- 2. Chemical (alcohol, tobacco, acidic foods, regular use of in- cheal or nasogastric], surgery in oral cavity) halers, drugs, and other noxious agents) 18. Decreased platelets 3. Depression 19. Immunocompromised 4. Immunosuppression 20. Impaired salivation 5. Aging-related loss of connective, adipose, or bone tissue 21. Radiation therapy 6. Barriers to professional care 22. Barriers to oral self-care 7. Cleft lip or palate 23. Diminished hormone levels (women) 8. Medication side effects 24. Stress 9. Lack of or decreased salivation 25. Loss of supportive structures 10. Trauma 11. Pathologic conditions—oral cavity (radiation to head or RELATED CLINICAL CONCERNS neck) 12. NPO status for more than 24 hours 1. Any condition requiring immobilization of patient 13. Mouth breathing 2. Burns: chemical, thermal, or radiation 14. Malnutrition or vitamin deficiency 3. Accidents: motor vehicle, farm equipment, motorcycles, and so on 15. Dehydration 4. AIDS 16. Ineffective oral hygiene 5. Congestive heart failure 6. Diabetes mellitus HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Skin Integrity If the tissue damage involves membranes, then the best diagnosis is Impaired only the skin and its subcutaneous tissues, then the Oral Mucous Membrane. Impaired Tissue Integrity most correct diagnosis is Impaired Skin Integrity. Risk is a higher-level diagnosis and would cover a for Impaired Skin Integrity would be the most wider range of tissue types. Impaired Oral Mucous appropriate diagnosis if the patient is presenting a Membrane and the two diagnoses related to Skin majority of risk factors for a skin integrity problem but Integrity are more specific and exact diagnoses and the problem has not yet developed. should be used before Impaired Tissue Integrity if Impaired Oral Mucous Membrane If the tissue the problem can be definitively isolated to either damage involves only the oral mucous the oral mucous membrane or the skin. EXPECTED OUTCOME TARGET DATES Will exhibit no signs or symptoms of increased tissue integrity Tissue integrity problems can begin developing within hours of a problems (e.g., increased size or infection) by [date]. patient’s admission if caution is not taken regarding turning, clean- ing, and so on. Therefore, an initial target date of 2 days after ad- mission would be most appropriate. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Perform active or passive ROM at least once per shift at [state Stimulates circulation, which provides nourishment and carries times here]. away waste, thus reducing the likelihood of tissue breakdown. • Ambulate to extent possible. • Change position at least hourly, and teach the patient to change position at least every 30 min. Do not position on affected area. • If the patient is unable to turn self, have several persons available to help lift, then turn. • Gently massage pressure points and bony prominences following each position change. • Teach the patient and significant others how to turn the patient without shearing force being involved. Be sure bed has siderails and a trapeze (overhead) bar for assistance with turning. Move slowly. (continued) Copyright © 2002 F.A. Davis Company TISSUE INTEGRITY, IMPAIRED 183 (continued) ACTIONS/INTERVENTIONS RATIONALES • Use soft, wrinkle-free linen only. • Place cornstarch or powder on linens. • Make sure footboard is in place for the patient to use for bracing. • Avoid use of rubber or plastic in direct contact with the patient. • Reduce pressure on affected skin surface by using: Pressure predisposes tissue breakdown. � Egg crate mattress � Alternating air mattress � Sheepskin � Commercial wafer barriers � Thick dressing used as pad on bony prominences � Bed cradle • Collaborate with dietitian regarding well-balanced diet. Assist Prevents tissue breakdown due to negative nitrogen balance. the patient to eat as necessary. • Monitor dietary intake, and avoid irritant food and fluid intake These factors would increase probability of oral mucous membrane (e.g., highly spiced food or extremes of temperature). problems. • Encourage fluid intake to at least 2000 mL per 24 h. Maintains fluid and electrolyte balance, which is necessary for tissue repair and normal functioning. • Measure and total intake and output every 8 h. • Cleanse perineal area carefully after each urination or bowel Allowing body wastes to remain on skin promotes tissue movement. Monitor closely for any urinary or fecal incontinence. breakdown. Incontinence would increase probability of such an event. • Teach the patient principles of good skin hygiene. Promote self-care and self-management to prevent problem. • Have the patient cough and deep-breathe every 2 h on Basic care measures to offset other complications that develop in [odd/even] hour. tandem with impaired tissue integrity. • Administer oral hygiene at least 3 times a day after each meal Basic care measures to maintain oral mucosa. and as needed (PRN): � Brush teeth, gums, and tongue with soft-bristled brush, sponge stick, or gauze-wrapped finger. � Floss teeth. � Rinse mouth thoroughly after brushing. Avoid commercial mouthwashes and preparations with alcohol, lemon, or glycerin. Use normal saline or oxidizing agent (mild hydrogen peroxide solution, Gly-Oxide, sodium bicarbonate solution). � If the patient is unable to rinse, turn on side and do oral irrigation. � Teach the patient how to use water pick. � Teach the patient and significant others proper oral hygiene. � If the patient has dentures, cleanse with equal parts of hydrogen peroxide and water. � Apply lubricant to lips at least every 2 h on [odd/even] hour. • Maintain good body hygiene. Be sure the patient has at least a sponge bath every day unless skin is too dry. • Monitor for signs of infection at least daily. Infection, through production of toxins, wastes, and so on, increases the probability of tissue damage. • Keep room temperature and humidity constant. Room Keeps skin cool and dry to prevent perspiration. temperature should be kept close to 72F and humidity at a low level unless otherwise ordered. • Darken room, as necessary, to protect eyes. • Encourage the patient to chew sugar-free gum to stimulate salivation. • Administer medications as ordered and record response (e.g., topical oral antibiotics, analgesic mouthwashes). Record response within 30 min of administration. • Encourage the patient to avoid smoking. Highly irritating to mucous membranes. • Provide between-meal food or fluids that the patient has identified as soothing, e.g., warm or cool. • If lesions develop, cleanse area daily at [time] according to prescribed regimen. • Protect open surface with such products as: � Karaya powder � Skin gel (continued) Copyright © 2002 F.A. Davis Company 184 NUTRITIONAL-METABOLIC PATTERN (continued) � Wafer barrier � Other commercial skin preparations • Collaborate with an enterostomal therapist and physician regarding care specific to the patient (list individualized care procedures here). • Change dressings when needed using aseptic techniques. Collaborate with physician regarding dressing type and use of topical agents. • Teach the patient and significant others care of the wound prior Basic care measures for impaired skin integrity. to discharge. • Avoid use of adhesive tape. If tape must be applied, use nonallergic tape. • Avoid use of doughnut ring. • Use mild, unscented soap (or soap substitute) and cool or lukewarm water. • Avoid vigorous rubbing, but do massage gently using a lanolin-based unscented lotion. • Pat area dry. Be sure area is thoroughly dry. • Expose to air, sunlight, or heat lamp at least 4 times a day at [state times here]. Check the patient at least every 5 min if using heat lamp. • Monitor: These measures would allow early detection of any complications. � Skin surface and pressure areas at least every 4 h at [state times here] for blanching, erythema, temperature difference (e.g., increased warmth), or moisture � Size and color of lesion at least every 4 h at [state times here] � Fluid and electrolyte balance • Particularly watch for signs or symptoms of edema. Collaborate with physician regarding frequency of measurement of electrolyte levels. • Caution the patient and assist to avoid scratching irritated areas: Avoids further irritation of already damaged tissue. � Trim and file nails. � Apply cool compresses. • Collaborate with physician regarding medicated baths (e.g., oatmeal) and topical ointments. • Teach the patient to press rather than scratch area that is itching. • Refer to community health agencies and other health care Provides on-going support and cost-effective use of available providers as appropriate. resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Handle the infant gently; especially caution paramedical The epidermis of infants and young children is thin and lacking in personnel regarding need for gentle handling. subcutaneous depth. Others, such as x-ray technicians, may not realize the fragile nature of skin as they carry out necessary procedures. • Place the patient on sheepskin or flotation pad, or if the parents Alternating surface contact and position favors circulatory return to choose, allow the infant or child to be held frequently. central venous system. • Caution the patient and parents to avoid scratching irritated Anticipate potential injury of delicate epidermis, especially when area: irritation may prompt itching. � Trim nails with appropriate scissors; receive parental permission if necessary. � Make small mitts if necessary from cotton stockinette used for precasting. • Monitor perineal area for possible allergy to diapers. Various synthetics in diapers may evoke allergenic responses and either cause or worsen existent skin irritation. • Encourage fluids: Adequate hydration assists in normal homeostatic mechanisms that � Infants: 250–300 mL/24 h affect the skin’s integrity. � Toddler: 1150–1300 mL/24 h � Preschooler: 1600 mL/24 h (These are approximate ranges. The physician may order specific amounts according to the child’s age and condition.) (continued) Copyright © 2002 F.A. Davis Company TISSUE INTEGRITY, IMPAIRED 185 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide protection such as bandage or padding to tissue site Anticipation and protection from injury serves to limit the depth involved. and/or degree of impaired skin integrity. • Monitor and document circulation to affected tissue via: These factors represent basic appropriate criteria for circulatory � Peripheral arterial pulses checks. They may be added to in instances of specific concerns � Blanching or capillary refill such as compartment syndrome associated with hand trauma. � Tissue color � Sensation to touch or temperature � Tissue general condition, e.g., bruising or lacerations � Drainage, e.g., amount, odor, or color � ROM limitations • Administer oral hygiene according to needs and status: Appropriate oral hygiene decreases the likelihood of altered � Glycerin and lemon swabs for NPO infant integrity of surrounding tissues and is critical for care of � Special orders for postoperative cleft palate or cleft lip repair associated oral disorders. • Teach the parents to limit time the infant sucks bottle in Evidence suggests that bottle mouth syndrome is prevented by not reclining position to best prevent bottle mouth syndrome and having the infant go to sleep with bottle. Completion of feeding decayed teeth. and removal of bottle is suggested before placing the infant in crib. • Protect the altered tissue site as needed during movement by Provision of support and usual use of body parts favor adequate providing support to the limb. circulation and prevent further injury. • Provide ROM and ambulation as permitted to encourage vascular return. • Position the patient while in bed so that the head of the bed is Appropriate venous return is favored by resultant gravity with limb elevated slightly and involved limb is elevated approximately higher than heart. 20 degrees. • Address ineffective thermoregulation, and especially protect the In severe instances of ineffective thermoregulation or related patient from chilling or shock due to dehydration or sepsis. pathology, there may not be the usual manifestations of derivations from normal. It may also be difficult to assess sensation in the young infant because of the infant’s inability to provide verbal feedback. • Use restraints judiciously for involved limb or body site. Any undue constriction or threat to circulation must be weighed appropriately in making decisions whether or not to restrain the child. • Monitor intravenous infusion and administration of medications This is usual protocol for IV therapy and must be considered cautiously. Avoid use of sites in close proximity to

area of paramount as IV medications or solutions pose serious threats to impaired tissue integrity. the veins and surrounding tissues. • Allow the patient and family time to express concerns by Reduces anxiety because their concerns can be made known and providing at least 30 min per shift for family counseling. their feelings valued. (State times here.) • Teach the patient and family: Appropriate education serves to build self-confidence and effects � Need for follow-up care long-term compliance with treatment and health management. � Signs and symptoms to be reported: (1) Increased temperature (101F or higher) (2) Foul odors or drainage (3) Delayed healing or increase in damage site size (4) Loss of sensation or pulsation in limb or site (5) Any increase in pain � Prosthetic device if indicated � Aids in mobility, such as crutches or walker � Need to avoid constrictive clothing � Appropriate dietary restriction or needs Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Monitor perineum and rectum after childbirth for injury or Assesses basic physical condition as a basis for providing care and healing at least once per shift at [state times here]. Monitor preventing complications. episiotomy site for redness, edema, or hematomas each 15 min immediately after delivery for 1 h, then once each shift thereafter. • Collaborate with physician regarding: Provides comfort and promotes healing. � Applying ice packs or cold pads to perineum for the first 8–12 h after delivery to reduce edema and increase comfort (continued) Copyright © 2002 F.A. Davis Company 186 NUTRITIONAL-METABOLIC PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Sitz baths twice a day at [state times here] and as necessary for pain and discomfort � Analgesics and topical anesthetics as necessary for pain and discomfort • Teach good perineal hygiene and self-care: Promotes healing and encourages self-care. � Rinse perineal area with warm water after each voiding. � Pat dry gently from front to back to prevent contamination. � Apply perineal pad from front to back to prevent contamination. � Change pads frequently to prevent infection and irritation. • Provide factual information on resumption of sexual activities Provides basic information to promote safe self-care. after childbirth: � First intercourse should be after adequate healing period (usually 3–4 wk). � Intercourse should be slow and easy (woman on top can better control angle, depth, and penetration). • Teach postmenopausal women the signs and symptoms of Provides basic information that promotes self-care and health atrophic vaginitis: maintenance. � Watery discharge � Burning and itching of vagina or vulva • Encourage examinations (Pap smears) for estrogen levels at least annually. • In collaboration with physician, encourage use as needed of: � Estrogen replacement creams or vaginal suppositories � Extra lubrication during intercourse • Teach breastfeeding mothers about breast care. Provides basic information that assists in preventing skin � Inspect for cracks or fissures in nipples. breakdown and promotes self-care and successful lactation. � Wear supportive bra (breast binder to relieve engorgement). � Shower daily, do not use soap on breast, allow to air dry. � Use lanolin-based cream (vitamin E cream, Massé Breast cream, or A and D cream) to prevent drying and cracking of nipples. • Enhance let-down reflex: Promotes let-down reflex and successful breastfeeding. � Nurse early and frequently. Ten minutes on each side is easier on sore nipples than nursing less frequently. � Nurse at both breasts each feeding. Switch sides to begin nursing each time, e.g., if the baby nursed first on left side at last feeding, begin on right side this time. A safety pin or small ribbon on bra strap will remind the mother which side she used first last time. � Change positions from one feeding to next (distributes sucking pressure). � Check the baby’s position on breast. Be certain areola is in mouth, not just nipple. � Begin nursing on least sore side first, if possible, then switch the baby to other side. � Apply ice to nipple just before nursing to decrease pain (fold squares, put them in the freezer and apply as needed). • Collaborate with physician regarding analgesics as needed. Caution the patient to not take over-the-counter medication because some medications are passed to the baby via breast milk. NOTE: Between the 3rd and 6th months of pregnancy, the process of tooth calcification (hardening) begins in the fetus. What the mother consumes in her diet will affect the development of the unborn child’s teeth. A well-balanced diet usually provides correct amounts of nutrients for both the mother and the child. • Teach the patient to practice good oral hygiene at least twice a Promotes sense of well-being. Assists in promoting proper growth day as well as PRN: and development of the fetus, and encourages health maintenance. � Each time the patient eats and, if nauseated and vomiting, vomits, the patient should clean gums and teeth. (continued) Copyright © 2002 F.A. Davis Company TISSUE INTEGRITY, IMPAIRED 187 (continued) ACTIONS/INTERVENTIONS RATIONALES � If the smell of toothpaste or mouth rinse makes the patient nauseated, the patient should use baking soda. • Reduce the number of times sugar-rich foods are eaten between meals. • Teach the patient to snack on fruits, vegetables, cheese, cottage Provides basic information to the patient that promotes health cheese, whole grains, or milk. maintenance and increases awareness of need for self-care. • Have the patient increase daily calcium intake to at least a total of 1.2 g of calcium per day. • Collaborate with obstetrician and dentist to plan needed dental care during pregnancy. • Assist in planning best time in pregnancy for dental visits: � Not during the first 3 months if: (1) Previous obstetric history includes miscarriage (2) Threatened miscarriage (3) Other medical indications (4) Hypersensitive to gagging (will increase nausea and vomiting) � Not during the last 3 months if: (1) Not able to sit in dental chair for long periods of time (2) Obstetric history of premature labor • Instruct the patient to have x-ray examinations only when it is Prevents x-ray exposure to the fetus. absolutely necessary. Caution the patient to request a lead apron when having x-ray examinations. ADDITIONAL INFORMATION Nursing actions for newborn health immediately follow the Women’s Health nursing actions. As previously mentioned, newborn actions are included in this section because newborn care is most often administered by nurses in the obstetric or women’s health area. Focus needs to be made on the newborn simply because the newborn’s oral mucous membrane problems can be easily overlooked. • In collaboration with dentist, teach the parents the oral and dental needs of the neonate: � Use of fluoride � Proper use of pacifiers � Do not use homemade pacifiers � Use pacifiers recommended by dentist � Allowing the infant who is teething to chew on soft toothbrush (will encourage later brushing of teeth because it allows the infant to become familiar with toothbrush in mouth) � Holding on to brush � Giving brush to the infant only when adult is present • Teach the parents how to administer oral hygiene: � Massage and rub the infant’s gums with finger daily. � Inspect oral cavity daily for hygiene and problems. • Take the infant for first dental visit between 18 mo and 2 yr of age. • Dental caries (decay) can be a result of prolonged nursing or Promotes good health and provides information as a basis for delayed weaning: parental care of the infant. Assists in preventing infection. � Do not allow the infant to nurse at breast or bottle beyond required feeding time. � Do not allow the infant to sleep habitually at the breast or with a bottle in the mouth. � Teach the neonate’s parents to: (1) Avoid giving sweet liquids (soft drinks) or fruit juices in bottle. (2) Wean child from bottle to cup soon after first birthday. (3) When continuing to nurse the infant, give water in cup soon after first birthday. (4) Use good handwashing techniques to prevent infection with or reinfection of thrush. (5) Not place the infant on sheets where the mother has been sitting. (6) Thoroughly clean breast or bottle-feeding equipment. Copyright © 2002 F.A. Davis Company 188 NUTRITIONAL-METABOLIC PATTERN Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Refer to Chapter 8 for stress-reduction measures and interventions for the stressors that produce psychogenic skin reactions. • If the client is placed in restraints, monitor the integrity of skin under restraints every hour. • Apply lanolin-based lotion and cornstarch or powder to area Lubricates skin and decreases risk for breakdown. under restraint at least every 2 h on [odd/even] hour and PRN. � Pad restraints with nonabrasive materials such as sheepskin. Decreases mechanical friction against the skin, and decreases risk � Keep area of restraint next to the skin clean and dry. for breakdown. � Release restraints one at a time every 2 h on [odd/even] hour and PRN. Remove restraints as soon as the client will tolerate one-to-one care without risk to self or others. � Maintain proper movement and alignment of affected body Decreases mechanical friction on specific areas for long periods of parts. time, thus decreasing risk for breakdown. � Change the client’s position every 2 h on [odd/even] hour. � Offer the client fluids every 15 min. List preferred fluids here. � While the client is very agitated and physically active, Hydration improves skin condition. provide constant one-to-one observation. � While limb is out of restraints, have the client move limb Promotes circulation and assists in preventing the consequences of through ROM. immobility. � If the client is in four-point restraints, place him or her on Client safety is of primary importance. This positioning prevents side or stomach and change this position every 2 h on aspiration by facilitating drainage of fluids away from the airway. [odd/even] hour. � Monitor skin condition of pressure areas. � If the client is in four-point restraints, provide one-on-one Provides supportive environment to the client. observation. � Continually remind the client of reason for restraint and conditions for having the restraints removed. � Talk with the client in calm, quiet voice and use the client’s name. � Use restraints that are wide and have padding. Make sure padding is kept clean and dry and free of wrinkles. • If Impaired Tissue Integrity is the result of self-harm, place the Client safety is of primary importance. Provides ongoing client on one-to-one observation until the risk of future harm supervision to inhibit impulsive behavior, and encourages use of has diminished. alternative coping behaviors. • Monitor self-inflicted injuries hourly for the first 24 h for signs Early identification and treatment of infection can prevent more of infection and further damage. Note information on a flow serious damage. sheet. After the first 24 h, monitor on a daily basis. • Provide equipment and time for the client to practice oral Removes debris and food particles, thus reducing the risk of tissue hygiene at least after each meal. injury. • Discuss with the client lifestyle changes to improve condition of Alerts the client to lifestyle patterns that increase risk for injury to mucous membranes, including nutritional habits, use of tobacco oral mucous membranes. If risk factors are present, frequent product, use of alcohol, maintenance of proper hydration, and assessment and increased attention to oral hygiene can decrease the effects of frequent vomiting. risk of membrane breakdown. • Discuss with the client side effects of medications, such as antibiotics, antihistamines, phenytoin, antidepressants, and antipsychotics, that contribute to alterations in oral mucous membranes. • Teach the client to use nonsucrose candy or gum to stimulate Maintains hydration of membranes and decreases chance of flow of saliva. breakdown. • Teach the client to avoid excessive wind and sun exposure, These medications can cause photosensitivity.42 especially with antipsychotic drugs. • If the client is taking antipsychotic drugs, suggest the use of a sunscreen containing PABA. Copyright © 2002 F.A. Davis Company TISSUE INTEGRITY, IMPAIRED 189 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Nursing actions for this diagnosis in the gerontic patient are The incidence of dry skin in the older adult is increased as a result essentially the same as those for adult health and home health of decreased production of natural skin oils. with the following special notations: Use only superfatted, nonperfumed, mild, nondetergent, and hexaclorophine-free soap in bathing the patient.88 • When drying the skin after bathing, pat

the skin dry rather than Increases the moisture level of the patient’s skin. Careful attention to rubbing, and apply lubricating lotion while the skin is still damp. dry skin conditions in the older adult assists in maintaining tissue integrity for the older adult. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach self-monitoring techniques to prevent tissue breakdown Promotes self-care. and to initiate early treatment: � Inspect the skin at least daily. Change positions at least every 2 h. � Massage pressure points and bony prominences gently at least 3 times a day. � Avoid rubber or plastic mattress covers or sheets. � Use proper body alignment and padding to reduce pressure on affected areas. � At least once per day engage in physical activity (active or passive), which will develop a full ROM of all joints and relieve pressure on risk area. � Consult health care provider for treatment of actual skin lesions. � Avoid scratching lesions. • Teach signs and symptoms of tissue breakdown, e.g., redness Provides data for early intervention. over bony prominences, pain or discomfort in localized area, skin lesions, or itching. • Teach measures to promote tissue integrity: Provides knowledge and skills that will prevent or minimize skin � Keep skin clean and dry. Wash urine and feces off skin breakdown. immediately. � Maintain adequate hydration, e.g., oral fluids, mild soap for bathing, and use of nonscented lotion or petroleum jelly on skin after bathing. � Maintain adequate protein intake. � Use mild laundry detergent on clothes. Double-rinse clothes, linens, and diapers if skin is sensitive. � Change position at least every 2 h on [odd/even] hour. Avoid prolonged sitting, standing, or lying in one position. � Use sunscreen to prevent sun damage. � Avoid excessive wind and sun exposure. � Wear properly fitting shoes. � Avoid shearing force when moving in bed or chair. Copyright © 2002 F.A. Davis Company 190 NUTRITIONAL-METABOLIC PATTERN Tissue Integrity, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient have any signs or symptoms of increased tissue integrity problems (e.g., lesion has increased in width and/or depth, lesion has increased drainage, lesion has become infected)? Yes No Reassess using initial assessment factors. Record data, e.g., lesion has decreased in depth to less than 2 cm and in width to 3 cm. Has no drainage. Record RESOLVED. (May wish to use CONTINUE until lesion has healed). Is diagnosis validated? Delete nursing diagnosis, expected outcome, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., lesion has increased in depth by 2 cm and in width to 5 cm; drainage has increased from approx. Yes No 10 mL/h to approx. 20 mL/h. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company CHAPTER 4 Elimination Pattern 1. BOWEL INCONTINENCE 195 C. Reflex 2. CONSTIPATION, RISK FOR, ACTUAL, D. Stress AND PERCEIVED 199 E. Total 3. DIARRHEA 206 F. Urge 4. URINARY INCONTINENCE 211 G. Risk for Urge A. Actual 5. URINARY RETENTION 219 B. Functional Pattern Description 5. Are stools hard formed? a. Yes (Constipation) The elimination pattern focuses on bowel and bladder functioning. b. No Although excretion also occurs through the skin and the lungs, the 6. Does the patient have to strain to have bowel movement? primary mechanisms of waste excretion are the bowel and bladder. a. Yes (Constipation) A problem within the elimination pattern may be the primary b. No reason for seeking health care or may arise secondary to another 7. Does the patient believe he or she is frequently constipated? health problem such as impaired mobility. Very few of the other a. Yes (Perceived Constipation) patterns or nursing diagnoses will not have an ultimate impact on b. No the elimination pattern from either a physiologic, psychological, or 8. Does the patient expect to have a bowel movement at the same sociologic direction. time each day? Included in the elimination pattern are the individual’s habits in a. Yes (Perceived Constipation) terms of excretory regularity as well as aids the individual uses to b. No maintain regularity or any devices used to control either bowel or 9. Are bowel sounds increased? bladder incontinence. a. Yes (Diarrhea) b. No 10. Has number of bowel movements increased? Pattern Assessment a. Yes (Diarrhea) b. No 1. Is there stool leakage when the patient coughs, sneezes, or 11. Does the patient complain of loose, liquid stools? laughs? a. Yes (Diarrhea) a. Yes (Bowel Incontinence) b. No b. No 12. Is there increased frequency of voiding? 2. Is there involuntary passage of stool? a. Yes (Urinary Incontinence; Stress Incontinence; Urge In- a. Yes (Bowel Incontinence) continence) b. No b. No 3. Does the patient take laxatives on a routine basis? 13. Is there dribbling of urine when the patient laughs, coughs, or a. Yes (Constipation, Perceived Constipation) sneezes? b. No a. Yes (Stress Incontinence) 4. Has number of bowel movements decreased? b. No a. Yes (Constipation) 14. Once need to void is felt, is the patient able to reach toilet in b. No time? 191 Copyright © 2002 F.A. Davis Company 192 ELIMINATION PATTERN a. Yes ileum and is approximately 20 feet in length and 1 inch in diame- b. No (Urge Incontinence; Functional Incontinence) ter. The large bowel includes the cecum, colon, and rectum and ter- 15. Does the patient complain of bladder spasms? minates at the anus. The large bowel is approximately 5 feet long a. Yes (Reflex Incontinence; Urge Incontinence) and 21⁄2 inches in diameter. The small bowel and large bowel con- b. No nect at the ileocecal valve.2 16. Is there a decreased awareness of the need to void? The intestines receive partially digested food from the stomach a. Yes (Reflex Incontinence; Total Incontinence) and move the food element through the lower tract, thus assisting b. No in proper absorption of water, nutrients, and electrolytes. The in- 17. Is there a decreased urge to void? testines also provide secretory and storage functions. They secrete a. Yes (Reflex Incontinence) mucus, potassium, bicarbonate, and enzymes. b. No The chyme (small intestine contents) is moved by peristalsis, and 18. Does the patient void in small amounts? the feces (large intestine contents) are propelled by mass move- a. Yes (Urge Incontinence; Urinary Retention) ments that are stimulated by the gastrocolic reflex. The gastrocolic b. No reflex occurs in response to food entering the stomach and causing 19. Is there urine flow without bladder distention? distention, so mass movement occurs only a few times a day. The a. Yes (Total Incontinence) gastrocolic reflex occurs within 30 minutes after eating and is most b. No predominant after the first meal of the day. Therefore, after the first 20. Is the bladder distended? meal of the day is the most frequent time for bowel elimination. a. Yes (Urinary Retention) Other reflexes involved in elimination are the duodenocolic reflex b. No and the defecation reflex. The duodenocolic reflex is stimulated by 21. Is there decreased urine output? the distention of the duodenum as food passes from the stomach to a. Yes (Urinary Retention) the duodenum. The gastrocolic and duodenocolic reflexes stimu- b. No late rectal contraction and, usually, a desire to defecate. The defe- cation reflex occurs in response to feces entering the rectum. This Conceptual Information reflex promotes relaxation of the internal anal sphincter, thus also promoting a desire to defecate. Extra fluids upon morning waking Elimination, simply defined, refers to the excretion of waste and potentiate the gastrocolic reflex. If the fluids are warm or contain nondigested products of the metabolic process. Elimination is es- caffeine, they will also stimulate peristalsis.1,2 sential in maintaining fluid, electrolyte, and nutritional balance of The secretions of the gastrointestinal tract assist with food passage the body. A disruption in an individual’s usual elimination pattern and further digestion. The passage rate of the contents through the can be life-threatening, because a person cannot live long without intestines helps determine the absorption amount. The small intes- the ability to rid his or her body of waste products.1,2 tine is responsible for about 90 percent of the absorption of amino Elimination depends on the interrelated functioning of the gas- acids, sodium, calcium chloride, fatty acids, bile salts, and water. trointestinal system, urinary system, nervous system, and skin. This Potassium and bicarbonate are excreted. The usual amount of time chapter discusses only the lower urinary tract and gastrointestinal for chyme to move from the stomach to the ileocecal valve varies from tract; the skin and nervous system are related to nursing diagnoses 3 to 10 hours. It takes approximately 12 hours for feces to travel from in other chapters. Also, because the nursing diagnoses related to the ileocecal valve to the rectum. One bowel movement may be the elimination refer only to elimination and not the collection and result of meals eaten over the past 3 to 4 days, but most of the food formation of the waste materials, inclusion of other conceptual in- residue from any particular meal will have been excreted within 4 formation would be confusing. days. Passage of contents is primarily influenced by the amount of Our society has a dichotomous attitude toward elimination. A great residue and the motility rate. Feces are normally evacuated on a mod- deal of time, effort, and money is expended in designing and adver- erately regular schedule, but the schedule will vary from three times tising bathrooms and aids to elimination, but to discuss elimination is daily to once per week depending on the individual. considered rude.1 Therefore, obtaining a reliable, complete elimina- When proper absorption does not occur, necessary nutrients and tion pattern assessment may be difficult. Added to this difficulty is the electrolytes are lost for subsequent body use. Small bowel loss can fact that each person has his or her own normal elimination habit. cause metabolic acidosis and hypokalemia. Large bowel loss can Elimination is highly individualized and can be influenced by age, lead to dehydration and hyponatremia. circadian rhythms, culture, diet, activity, stress, and a number of The squatting, leaning forward position is the most supportive other factors. Elimination has elements of both involuntary and vol- position for defecation because it increases intra-abdominal pres- untary control. The mechanisms that control the production of waste sure and promotes easier abdominal and perineal muscle contrac- materials and the neural signals that the bladder or bowel needs to tion and relaxation. Beside positioning, diet, and fluid intake, other be emptied are primarily involuntary. However, each person can aids to elimination include enemas and laxatives. usually control both the timing of bowel and bladder evacuation and Enemas assist in evacuation through promotion of peristalsis, the use of abdominal and perineal muscles to assist in evacuation. chemical irritation, or lubrication. Volume enemas, 500 to 1000 Food and fluid intake are extremely important in elimination. A mL of fluid, cause distention, which increases peristalsis. The ad- fluid intake of 2000 mL/day and a food intake of high-fiber foods dition of heat and soapsuds, for example, adds chemical irritation would, in the majority of instances, ensure an adequate elimination and increases peristalsis. Straight tap-water enemas should be used pattern.3,4 Alteration in elimination may cause psychosocial prob- cautiously, because they are hypotonic and may disturb electrolyte lems, such as social isolation due to embarrassment, as well as balance. Electrolyte enemas are usually prepackaged and are hy- physiologic problems, such as fluid and/or electrolyte imbalance. pertonic. Hypertonic enemas increase fluid amounts in the bowel through osmosis, thus slightly increasing distention and providing BOWEL ELIMINATION a relatively mild chemical irritation. Both the distention and irrita- tion also result in increased peristalsis. Oil enemas are usually The lower gastrointestinal tract includes the small and large in- small-volume enemas (100 to 200 mL) and provide lubrication as testines. The small bowel includes the duodenum, jejunum, and well as stool softening.1,5 Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 193 Laxatives assist elimination through producing bulk, providing intake, environmental temperature, fluid requirements of other or- lubrication, causing chemical irritation, or softening stool. The ac- gans, presence of open wounds, output by other areas (skin, bowel, tion of laxatives ranges from harsh to mild. or respiration),

and medications such as diuretics. The amount of Both laxatives and enemas can be abused. Persistent use of either solutes in the urine, an intact neuromuscular system, and the ac- will diminish normal reflexes so that the individual will begin to re- tion of the antidiuretic hormone also influence output. A significant quire more and more aid. The individual then establishes an aid- impact on urinary output is the opportunity to void at socially ac- dependent habit just as a drug abuser does. ceptable times in private.1 Although constipation and diarrhea are the two most common Inadequate urinary output may arise from either the kidney not problems with bowel elimination, flatulence may be an associated producing urine (suppression) or blockage of urine flow (retention) problem. Flatus (intestinal gas) is normal. A problem arises when somewhere between the kidney and external urinary meatus. Sup- the individual cannot pass the gas or when abnormally large pression may result from disease of the kidneys or other body struc- amounts of gas are produced. Flatus is produced by swallowed air, tures and inadequate fluid intake. Retention may be either me- diffusion of gases from the bloodstream to the gastrointestinal tract, chanical or functional in nature. Mechanical retention is due to carbon dioxide formed by the action of bicarbonate with hy- anatomic blockage, such as a stricture or a calculus. Functional re- drochloric acid or fatty acids, and bacterial decomposition of food tention actually refers to any retention that is not mechanical and in- residue. Common causes of gas problems include gas-producing cludes such areas as neurogenic problems.2 foods (beans, for example), highly irritating foods (pizza, for ex- Urinary control relates to the integrity and strength of the urinary ample), constipating medications (codeine, for example), and inac- sphincters and perineal musculature. Inability to control urinary tivity. The problems relate directly to the amount of gas produced output will soon lead to social isolation due to embarrassment over and decreased motility. Increased flatus causes distention that, in control and odor. Urinary incontinence is more common than most turn, can cause pain, respiratory difficulty, and further problems health care professionals realize. Studies have indicated that urinary with intestinal motility.1 incontinence is quite common among healthy premenopausal mid- As previously mentioned, any bowel elimination problem can ulti- dle-aged women.6,7 These studies found no relationship between mately be life-threatening. Any bowel elimination problem, whether continence status, number of children, history of gynecologic it be constipation, diarrhea, or flatulence, that lasts more than 1 to 2 surgery, smoking, physical activity, or intake of alcohol and caf- weeks in an adult or more than 2 to 3 days for an infant or elderly per- feine. The studies found also that very few of these women sought son requires immediate health care intervention. treatment for this incontinence. Bladder-retraining programs may vary according to individual URINARY ELIMINATION hospitals and physicians. Consultation with a rehabilitation nurse clinician provides the most current and reliable information re- The lower urinary tract is composed of the ureters, bladder, and garding a quality bladder-retraining program.8 Two measures that urethra. These anatomic structures serve as storage and excretory may assist with incontinence are Credé’s maneuver and the Valsalva pathways for the waste secreted by the kidneys. The ureters extend maneuver. Credé’s maneuver involves placing the fingertips to- from the kidney pelvis to the trigone area in the bladder. The gether at the midline of the pelvic crest, then massaging deeply and ureters are small tubes composed of smooth muscle that propels smoothly down to the pubic bone. Check with the physician first, urine by peristalsis from the kidney to the bladder. The bladder because there are contraindications, such as ureteral reflux.5 The stores the urine until it is excreted through the urethra. Between the Valsalva maneuver involves asking the patient to simulate having a base of the bladder and the top of the urethra is the urethral sphinc- bowel movement. Have the patient take a deep breath, hold it, and ter. The sphincter opens under learned voluntary control. Opening then bear down as if expelling feces. Check with the physician first, the urethral sphincter allows the urine to pass through the urethra because there are contraindications, such as glaucoma, eye surgery, and meatus for elimination. The female urethra is approximately 3 and impaired circulation.5 to 5 cm long, and the male urethra is approximately 20 cm long.2 Urine is a waste product formed as a part of body metabolism. The desire to void occurs when the bladder (adult) has reached Urine is normally produced at a rate of 30 to 50 mL/h. Under nor- a capacity of 250 to 450 mL of urine. As urine collects to the blad- mal circumstances, output will balance with intake approximately der capacity, the stretch receptors in the bladder muscle are acti- every 72 hours. An hourly output of less than 30 mL, a 24-hour vated. This stretching stimulates the voiding reflex center in the output of 500 mL or less, or an intake-output imbalance lasting spinal cord (sacral levels 2, 3, and 4), which sends signals to the longer than 72 hours requires immediate intervention.1,4 midbrain and the pons. These stimuli result in inhibition of the spinal reflex center and pudendal nerve, which allows relaxation of the external sphincter and contraction of the bladder, and voiding Developmental Considerations occurs. The bladder is under parasympathetic control, with the learned voluntary control being guided by the cortex, midbrain, Elimination depends on the interrelatedness of fluid intake, muscle and medulla.1,2 tone, regularity of habits, culture, state of health, and adequate nu- The anatomically correct positions for voiding are sitting for the trition.9 female and standing for the male. It is important to note that in some cultural groups the correct voiding position for the male is INFANT squatting. Either standing or squatting is anatomically correct. Dif- ficulties arise if the male is lying down, for example, in traction or Kidney function does not reach adult levels until 6 months to 1 year a body cast. An individual generally voids 200 to 450 mL each void- of life. Nervous system control is inadequate, and renal function does ing time, and it is within normal limits to void 5 to 10 times per not reach a mature status until approximately 1 year of life.9 Voiding day. Common times for urination are upon arising and before re- is stimulated by cold air. The infant usually voids 15 to 60 mL at each tiring. Other times will vary with habits and correspond with work voiding during the first 24 hours of life and may void reflexively at breaks and availability of toilet facilities.1,2 birth. If the infant has not voided by 12 hours after birth, there is Urine volume varies according to the individual. Urine volume cause for concern. By the third day, the infant may void 8 to 10 times depends on normal kidney functioning, amount of fluid and food during each 24 hours, equaling about 100 to 400 mL. Urinary out- Copyright © 2002 F.A. Davis Company 194 ELIMINATION PATTERN put is affected by the amount of fluid consumed, the amount of ac- ing to bed, and get the child up at least once during the night to as- tivity (increased activity equals less urine), and the environmental sist in attaining nighttime control. temperature (increased temperature equals less urine).10 Uric acid In order to toilet train, the parent should watch for patterns of crystals may be found in concentrated urine, causing a rusty discol- defecation. Eating stimulates peristaltic activity and evacuation. oration to the diaper.10 The child can then be taken to the toilet at the expected time after The muscles and elastic tissues of the infant’s intestines are eating. The child should be told what is expected while on the toi- poorly developed, and nervous system control is inadequate. Wa- let. Give the child enough time to evacuate the bowel, but do not ter and electrolyte absorption is functional but immature. The in- have the child sit on the toilet too long. The child (and the parent) testines are proportionately longer than in the adult. Although may then become frustrated. some digestive enzymes are present, they can break down only sim- Children at this age like to please their parents. Evacuation of the ple foods. These digestive enzymes are unable to break down com- bowel is a natural process and should not be approached as if it is plex carbohydrates or protein. a dirty or unnatural process. The children should be rewarded Meconium is the first waste material that is eliminated by the when able to defecate, but should not be punished if unable to have bowel. This usually occurs during the first 24 hours. After 24 hours, a bowel movement. Children should feel proud of their accom- the characteristics of the bowel movement change as it mixes with plishment; children should never be punished or made to feel milk. The characteristics of the stool depend on whether the infant ashamed for not giving what is expected. is breastfed or bottle-fed. The breastfed infant will have soft, semi- Children usually do not need enemas or laxatives to make them liquid stools that are yellow or golden in color. The bottle-fed in- regular. In fact, those artificial aids may be dangerous. Lack of fant will have a more formed stool that is light yellow to brown in parental understanding of the elimination process and child devel- color. opment, coupled with harsh punishment for “accidents,” may lead The infant may have 4 to 8 soft bowel movements a day during a child to an obsessive, meticulous, and rigid personality. the first 4 weeks of life. Flatus often accompanies the passage of Accidents can and do occur even after a child has been com- stool, and there may be a sour odor to the bowel movement. By the pletely toilet trained. These accidents usually occur because the fourth week of life, the number of bowel movements has decreased child ignores the defecation urge when he or she is engrossed in an to 2 to 4 a day. By 4 months, there is a predictable interval between activity and does not want to take the time to go to the bathroom bowel movements. or when other stressors have a higher priority at the moment. It is common for the infant to push or strain at stool. However, if the stools are very hard or dry, the infant should be assessed for SCHOOL-AGE CHILD constipation. The bottle-fed infant is more prone to constipation than the breastfed infant. The urinary system is functioning maturely by this age. The normal Infants sometimes suffer from what is known as colic. Colic is de- output is 500 mL/day. Urinary tract infections are common because scribed as daily periods of distress caused by rapid, violent peri- of careless hygiene practices in girls. The gastrointestinal system at- staltic waves and increased gas pressure in the rectum.10 The cause tains adult functional maturity during the school years. is unknown but may have to do with the simple (rather than the complex) digestive enzymes of the infant or a decreased amount of ADOLESCENT vitamins A, K, or E. Most authorities agree that colic disappears as digestive enzymes become more complex and when normal bacte- There are no noticeable differences in patterns of urinary elimina- rial flora accumulate.10 tion in this age group. The intestines grow in length and width. The muscles of the intestines become thicker and stronger. TODDLER AND PRESCHOOLER This developmental stage is important in developing bowel habits. The teenager is engaged in developing sexuality. This group By 2 years of age, the kidneys are able to conserve water and to con- may ignore warning signals for elimination because they do not centrate urine almost on an adult level, except under stress. The want to leave their activities or because of the close association of bladder increases in size and is able to hold approximately 88 mL the anus to the teenager’s developing sexual organs. Additionally, of urine. if a problem arises with elimination, adolescents are reluctant to Nervous system and gastrointestinal maturation has occurred talk about it with either their peers or an adult. during infancy and the beginning of the toddler years. By the time children are 2 to 3 years of age,

they are ready to control bowel and YOUNG ADULT bladder functioning. Bowel elimination control is usually attained first; daytime bladder control is second; and nighttime bladder con- There is no noticeable difference in patterns of elimination during trol is third. The child must be able to walk a few steps, control the this developmental period. Total urinary output for 24 hours is sphincter, recognize and interpret that the bladder is full, and be 1000 to 2000 mL. The rate of passage of feces is influenced by the able to indicate that he or she wants to go to the bathroom. The nature of the foods consumed and the physical health of the indi- child must also value dryness. He or she must recognize that it is vidual. Hemorrhoids are possible in this developmental group, es- more socially acceptable to be dry than to be wet. pecially young women. Parents should not attempt toilet training, even if the child is ready, if there are family or environmental stressors. Regression is ADULT normal during toilet training and, coupled with undue stress, could cause physical or psychosocial problems. Adequate daily fluid intake helps maintain proper elimination func- Bladder training takes time to accomplish. Both the parent and tions. There is a gradual decrease in the number of nephrons and the child must have patience and not get unduly upset when acci- therefore decreased renal functioning with age. Additionally, blad- dents occur. In fact, nighttime bladder control may not be attained der tone diminishes; thus, the adult may urinate more frequently. until age 5 to 8 years. Doctors and researchers disagree on the age Digestive enzymes (gastric acid, pepsin, ptyalin, and pancreatic at which nighttime bed-wetting (enuresis) becomes a problem.10 enzymes) begin to decrease. This may lead to an increasing incidence Parents should limit fluids at night, have the child void before go- of intestinal disorders, cancer, and gastrointestinal complaints. Copyright © 2002 F.A. Davis Company BOWEL INCONTINENCE 195 OLDER ADULT NANDA TAXONOMY: DOMAIN 3—ELIMINATION; CLASS 2—GASTROINTESTINAL SYSTEM Renal function is slowed by both the structural and functional aging changes, mainly because of decreases in the number of nephrons. NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; Vascular sclerosing also occurs in the renal system, and this, com- CLASS B—ELIMINATION MANAGEMENT bined with fewer nephrons, decreases available blood so that the glomerular filtration rate (GFR) becomes markedly reduced. Al- NOC: DOMAIN II—PHYSIOLOGIC HEALTH; though the GFR reduction is still sufficient to handle normal de- CLASS F—ELIMINATION mands, stress or illness can significantly alter the older adult’s renal status.11 Decreased concentrations and dilution ability of the kidneys DEFINING CHARACTERISTICS15 occur as a result of changes in the renal tubules. Waste products are effectively processed by the kidneys, but over a longer period of time. 1. Constant dribbling of soft stool The decreased efficiency of the kidneys makes older adults especially 2. Fecal odor vulnerable to medication side effects and problems regarding drug 3. Inability to delay defecation excretion.12 4. Urgency The older man may have an enlarged prostate gland. Prostatic en- 5. Self-report of inability to feel rectal fullness largement can lead to urethritis, incomplete bladder emptying, and 6. Fecal staining of clothing and/or bedding difficulty in starting the stream of urine. Bladder changes, resulting 7. Recognizes rectal fullness but reports inability to expel formed from loss of smooth muscle elasticity, can result in a decreased stool bladder capacity. Uninhibited bladder contractions may interrupt 8. Inattention to urge to defecate bladder filling and lead to a premature urge to void. Increased 9. Inability to recognize urge to defecate residual urine and incomplete emptying of the bladder result in a 10. Red perianal skin higher incidence of urinary tract infections in older adults of both RELATED FACTORS15 sexes. Changes in the gastrointestinal tract include a continued de- 1. Environmental factors (for example, inaccessible bathroom) crease in digestive enzymes and questionable changes in absorption 2. Incomplete emptying of bowel in the small intestines. The large intestine may have reduced blood 3. Rectal sphincter abnormality flow secondary to vascular twisting, and there is debate regarding 4. Impaction decreased motility in the colon. Problems related to constipation 5. Dietary habits may occur as a result of increased tolerance for rectal distention 6. Colorectal lesions rather than decreased motility.12 7. Stress Major factors that affect gastrointestinal and genitourinary func- 8. Lower motor nerve damage tion in older adults include immobility and medications. Immobil- 9. Abnormally high abdominal or intestinal pressure ity can lead to kidney stones; urinary tract infections secondary to 10. General decline in muscle tone stasis; and alterations in food intake, digestion, and elimination.13 11. Loss of rectal sphincter control Medications such as anticholinergics and opiates can result in de- 12. Impaired cognition layed motility in the gastrointestinal tract. Diuretics, hypnotics, and 13. Upper motor nerve damage antipsychotics must be considered in light of their effect on geni- 14. Chronic diarrhea tourinary function.14 15. Self-care deficit, toileting 16. Impaired reservoir capacity 17. Immobility 18. Laxative abuse APPLICABLE NURSING DIAGNOSES RELATED CLINICAL CONCERNS Bowel Incontinence 1. Alzheimer’s disease DEFINITION 2. Guillain-Barré syndrome 3. Spinal cord injury Change in normal bowel habits characterized by involuntary pas- 4. Intestinal surgery sage of stool.15 5. Gynecologic surgery HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Constipation The problem may really be due unable to appropriately care for his or her to constipation with impaction. Incontinence evacuation needs, incontinence may result. may occur because some feces are leaking Diarrhea Diarrhea relates to frequent bowel around the impaction site and the individual is movements, but the patient is aware of rectal filling unable to control its passage and thus appears and can control the feces until reaching the toilet. incontinent. With incontinence, the patient may not be aware of Self-Care Deficit, Toileting If the individual is rectal filling, and the stool passage is involuntary. Copyright © 2002 F.A. Davis Company 196 ELIMINATION PATTERN EXPECTED OUTCOME TARGET DATES Will have no more than one soft, formed stool per day by [date]. Target dates should be based on the individual’s usual bowel elim- ination pattern. Incontinence may require additional retraining time and effort. Therefore, a target date 5 days from admission would be most realistic. Also remember that there must be a realis- tic potential that bowel continence can be regained by the patient. NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Check for fecal impaction on admission, and implement nursing Impaction may lead to leakage of bowel contents around impacted actions for constipation if impaction is noted. area. • Record each incontinent episode when it occurs as well as the Assists in determining pattern of incontinence. amount, color, and consistency of each stool. • Record events associated with incontinent episode, including Assists in determining pattern of incontinence. events both before and after the episode (i.e., activity, stress, location, people present, etc). • Monitor anal skin integrity at least once per shift at [times]. Allows early detection of any tissue integrity problems. • Keep anal area clean and dry. Bowel contents are damaging to the skin and promote tissue integrity problems. • Provide room deodorizer and chlorophyll tablets for the patient. Decreases embarrassment due to odors. • Provide emotional support for the patient through teaching, The patient may find incontinence embarrassing and may try to providing time for listening, etc. isolate self. • Initiate bowel training at least 4 days prior to discharge: Establishes consistent pattern, and conditions control of elimination. � Suppository half-hour after eating. � Toilet half-hour after suppository insertion. � Toilet prior to activity. � Stimulate defecation reflex with circular movement in rectum using gloved, lubricated finger. • Teach the patient, beginning as soon after admission as possible: Basic knowledge promotes understanding of condition and assists � Pelvic floor strengthening exercises (see Constipation) the patient to change behavior as well as empowering the patient for � Diet, i.e., role of fiber and fluids self-care. � Use of assistive devices such as Velcro closings on clothes, pads � Perineal hygiene � Appropriate use of suppositories and antidiarrheal medications • Refer for home health care assistance. Child Health Nursing actions for Incontinence in the child are the same as those for Adult Health. Modifications would be made for child’s age and size, for example, medication dosage and fluid amounts. Women’s Health Bowel incontinence in women caused by uterine prolapse and pelvic relaxation with displacement of pelvic organs (particularly the rectum) is relieved only by surgical repair.16 Otherwise, nursing actions for bowel incontinence in Women’s Health are the same as in Adult Health. Copyright © 2002 F.A. Davis Company BOWEL INCONTINENCE 197 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • If a pattern forms around specific events, develop plan to: Promotes the client’s perceived control, and increases potential for � Encourage the person to use bathroom before the event. the client’s involvement in treatment plan. � Alter the manner in which specific task is performed to prevent stress [note alterations here]. � Discuss with the client alternative ways of coping with stress. (Refer to Chap. 8 for specific nursing actions related to reduction of anxiety and Chap. 11 for specific nursing actions related to Ineffective Coping.) • If assessment suggests secondary gains associated with episodes, Provides negative consequences for inappropriate coping behavior. decrease these by: � Withdrawing social contact after an episode � Having the client clean himself or herself. � Providing social contact or interactions with the client at times when no incontinence is experienced. • If not related to secondary gain, spend [number] min with the Verbalization of feelings in a nonthreatening environment models client after each episode to allow expression of feelings. acceptance of feelings and positive coping behavior. • Discuss with the client effects this problem has on lifestyle. Increases the client’s awareness of impact inappropriate coping behaviors have on lifestyle. Provides data for development of alternative coping, promoting the client’s perceived control. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Record events associated with incontinent episode. Assists in determining pattern of incontinence. Older adults may have difficulty in reaching commode or bathroom easily. • Monitor medication intake for potential to result in bowel Medications with a sedative effect may decrease the ability of the incontinence. patient to reach toilet facilities in a timely manner. • Teach toileting skills to caregivers of cognitively impaired older Depending on the stage of the disease, a person with dementia may adults. In early dementia, labeling the bathroom and reminding forget to toilet or have difficulty finding a bathroom that is not the individual to toilet may result in continence. readily identified. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the patient and family: These activities assist in preventing constipation and provide data � To use appropriately all prescribed and over-the-counter for early recognition of problem. medications � To monitor color, frequency, consistency, and pattern of symptoms � Measures to ensure adequate bowel elimination: (1) Proper diet (2) Fluid and electrolyte balance (3) Pelvic floor and abdominal exercises � To monitor skin integrity These measures prevent secondary problems from occurring as a � To keep bed linens and clothing clean and dry result of the existing problem. Copyright © 2002 F.A. Davis Company 198 ELIMINATION PATTERN Bowel Incontinence FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient having more than one soft stool per day? Yes No Reassess using initial assessment factors. Record data, e.g., has had no incontinent episodes for 3 days; has had one soft brown stool daily for past 2 days. Record RESOLVED. Delete nursing diagnosis, expected outcomes, Is diagnosis validated? target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., has had loose stools over past 3 days; unaware of 5 to 6 of theses stools each day Yes No until too late to go to bathroom. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 199 Constipation, Risk for, Actual, and Perceived f. Abdominal muscle weakness 2. Psychological DEFINITIONS a. Emotional stress b. Mental confusion Constipation A decrease in a person’s normal frequency of defe- c. Depression cation accompanied by difficult or incomplete passage of stool 3. Physiologic and/or passage of excessively hard, dry stool.15 a. Insufficient fiber

intake Risk for Constipation At risk for a decrease in a person’s normal b. Dehydration frequency of defecation accompanied by difficult or incomplete c. Inadequate dentition or oral hygiene passage of stool and/or passage of excessively hard, dry stool.15 d. Poor eating habits e. Insufficient fluid intake Perceived Constipation The state in which an individual makes a f. Change in usual foods and eating patterns self-diagnosis of constipation and ensures a daily bowel movement g. Decreased motility of gastrointestinal tract through abuse of laxatives, enemas, and suppositories.15 4. Pharmacologic a. Phenothiazines NANDA TAXONOMY: DOMAIN 3—ELIMINATION; b. Nonsteroidal anti-inflammatory agents CLASS 2—GASTROINTESTINAL SYSTEM c. Sedatives d. Aluminum-containing antacids NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; e. Laxative overdose CLASS B—ELIMINATION MANAGEMENT f. Iron salts g. Anticholinergics NOC: DOMAIN II—PHYSIOLOGIC HEALTH; h. Antidepressants CLASS F—ELIMINATION i. Anticonvulsants j. Antilipemic agents DEFINING CHARACTERISTICS15 k. Calcium channel blockers l. Calcium carbonate A. Constipation m. Diuretics 1. Change in bowel pattern n. Sympathomimetics 2. Bright red blood with stool o. Opiates 3. Presence of soft paste-like stool in rectum p. Bismuth salts 4. Distended abdomen 5. Mechanical 5. Dark or black or tarry stool a. Rectal abscess or ulcer 6. Increased abdominal pressure b. Pregnancy 7. Percussed abdominal dullness c. Rectal anal stricture 8. Pain with defecation d. Postsurgical obstruction 9. Decreased volume of stool e. Rectal anal fissures 10. Straining with defecation f. Megacolon (Hirschsprung’s disease) 11. Decreased frequency g. Electrolyte imbalance 12. Dry, hard, formed stool h. Tumors 13. Palpable rectal mass i. Prostate enlargement 14. Feeling of rectal fullness or pressure j. Rectocele 15. Abdominal pain k. Rectal prolapse 16. Unable to pass stool l. Neurologic impairment 17. Anorexia m. Hemorrhoids 18. Headache n. Obesity 19. Change in abdominal growling (borborygmi) C. Perceived Constipation 20. Indigestion 1. Expectation of a daily bowel movement with the resulting 21. Atypical presentation in older adults (e.g., change in men- overuse of laxatives, enemas, and suppositories tal status, urinary incontinence, unexplained falls, elevated 2. Expected passage of stool at same time each day body temperature) 22. Severe flatus 23. Generalized fatigue RELATED FACTORS15 24. Hypoactive or hyperactive bowel sounds 25. Palpable abdominal mass A. Constipation 26. Abdominal tenderness with or without palpable muscle 1. Functional resistance a. Habitual denial or ignoring of urge to defecate 27. Nausea and/or vomiting b. Recent environmental changes 28. Oozing liquid stool c. Inadequate toileting (e.g., timeliness, positioning for B. Risk for Constipation (Risk Factors) defecation, privacy) 1. Functional d. Irregular defecation habits a. Habitual denial or ignoring of urge to defecate e. Insufficient physical activity b. Recent environmental changes f. Abdominal muscle weakness c. Inadequate toileting (e.g., timeliness, positioning for defe- 2. Psychological cation, privacy) a. Emotional stress d. Irregular defecation habits b. Mental confusion e. Insufficient physical activity c. Depression Copyright © 2002 F.A. Davis Company 200 ELIMINATION PATTERN 3. Physiologic b. Pregnancy a. Insufficient fiber intake c. Rectal anal stricture b. Dehydration d. Postsurgical obstruction c. Inadequate dentition or oral hygiene e. Rectal anal fissures d. Poor eating habits f. Megacolon (Hirschsprung’s disease) e. Insufficient fluid intake g. Electrolyte imbalance f. Change in usual foods and eating patterns h. Tumors g. Decreased motility of gastrointestinal tract i. Prostate enlargement 4. Pharmacologic j. Rectocele a. Phenothiazines k. Rectal prolapse b. Nonsteroidal anti-inflammatory agents l. Neurologic impairment c. Sedatives m. Hemorrhoids d. Aluminum-containing antacids n. Obesity e. Laxative overdose B. Risk for Constipation f. Iron salts The risk factors also serve as the related factors. g. Anticholinergics C. Perceived Constipation h. Antidepressants 1. Impaired thought processes i. Anticonvulsants 2. Faulty appraisal j. Antilipemic agents 3. Cultural or family health belief k. Calcium channel blockers l. Calcium carbonate RELATED CLINICAL CONCERNS m. Diuretics n. Sympathomimetics 1. Anemias o. Opiates 2. Hypothyroidism p. Bismuth salts 3. Hemorrhoids 5. Mechanical 4. Renal dialysis a. Rectal abscess or ulcer 5. Abdominal surgery HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Imbalanced Nutrition, Less or More Than Body the gastrointestinal tract, peristalsis is slowed, Requirements This might be the primary nursing which may lead to a backlog of feces and to diagnosis. Either of these diagnoses influences the constipation. amount and consistency of the feces. Self-Care Deficit, Toileting This diagnosis may Deficient Fluid Volume This diagnosis might also also be the primary diagnosis. Difficulty in be the primary problem. The feces need adequate reaching appropriate toileting facilities and lubrication to pass through the gastrointestinal difficulty in cleansing oneself after toileting could tract. If there is a Deficient Fluid Volume, the feces lead to a decision to delay bowel movement, with is harder, more solid, and unable to move through a result of constipation. the system. Ineffective Individual Coping and Anxiety These Diarrhea or Bowel Incontinence Constipation can diagnoses are two psychosocial nursing diagnoses be misdiagnosed as Diarrhea or Bowel from which Constipation needs to be Incontinence. Diarrhea or incontinence may be a differentiated. Both of these psychosocial secondary condition to constipation, as semiliquid diagnoses initiate stress as an autonomic response, feces may pass around the area of constipation. and the parasympathetic system stimuli (which Impaired Physical Mobility This diagnosis could control motility of the gastrointestinal tract) are be the underlying cause of constipation. Decrease reduced. This reduced motility may lead to in physical mobility affects every body system. In constipation. EXPECTED OUTCOME TARGET DATES Will return, as nearly as possible, to usual bowel elimination habits Target dates should be based on the individual’s usual bowel elim- by [date]. ination habits. A target date 3 to 5 days from admission would be reasonable for the majority of patients. Copyright © 2002 F.A. Davis Company CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 201 NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Record amount, color, and consistency of feces following each Basic assessment of problem severity as well as monitoring bowel movement. Question the patient regarding bowel effectiveness of therapy. movements at least once per shift. Also record if no bowel movement on each shift. • Monitor and record symptoms associated with passage of bowel Allows early detection of additional problems. movement: � Any straining, pain, or headache � Any rectal bleeding or fissures • If fecal impaction: Prioritization of methods used to break up and remove impaction. � Attempt digital removal using gloves and lubrication. � Administer oil retention enema of small volume. Have the patient retain for at least 1 h. � Use small-volume saline enema if oil retention does not relieve impaction. • Collaborate with physician regarding use of glycerin or other types of suppositories. • Measure and total intake and output every shift. Be sure to Allows monitoring of fluid balance. include estimation of loss by perspiration. • Force fluids, of patient’s choice, to at least 2000 mL daily. Increases moisture and water content of feces for easier movement Encourage 8 oz of fluid every 2 h on [odd/even] hour beginning through intestines and anus. at awakening each morning. • Increase the patient’s activity to extent possible through Activity promotes stimulation of bowel and assists in elimination. ambulation at least 3 times per shift while awake. • Assist the patient with exercises every 4 h while awake. Have Strengthens pelvic floor and abdominal muscles. the patient repeat each exercise at least 5 times: � Bent-knee sit-ups � Straight- or bent-leg lifts � Alternating contraction and relaxation of perineal muscles while sitting in a chair and with feet placed apart on floor • Assist the patient with implementation of stress reduction Promotes relaxation and can increase feces passage through the techniques at least once per shift. intestines. • Digitally stimulate anal sphincter at scheduled times (usually Stimulates defecation reflex and urge. after meals) [state times here]. • Provide privacy and sufficient time for bowel elimination. Decreases stress and promotes relaxation, which increases likelihood of bowel movement. • Help the patient assume anatomically correct position for bowel Promotes effective use of abdominal muscles, and allows gravity to movements. assist in defecation. • Use rectal tube, heat, activity, and change of position, every 2 h Promotes passage of flatus. on [odd/even] hour, for problems with flatulence. • Monitor anal skin integrity at least once per shift. Straining at stool can cause splits and tears of the anal tissue. • Provide room deodorizer for the patient as needed. Helps eliminate odors, which decreases the patient’s embarrassment. • Use cool compresses to anus every 2 h as needed. Alleviates anal itching. • Teach the patient, starting as soon after admission as possible: Promotes understanding of self-care needs prior to discharge.17 � The importance of a bowel routine and the need to respond to the urge to defecate as soon as possible � To stimulate gastrocolic reflex through drinking prune juice or hot liquid upon arising � To allow sufficient time for bowel movement and plan time for elimination � To include high-fiber foods and extra liquid in daily diet � To avoid prolonged use of elimination aids such as laxatives and enemas � To avoid straining � To use proper perineal hygiene � To describe the relationship of diet and activity to bowel elimination (continued) Copyright © 2002 F.A. Davis Company 202 ELIMINATION PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Collaborate, as soon as possible after admission: Provides basic resources and information needed; promotes holistic � With dietitian, regarding a high-fiber, high-roughage diet approach to treatment. (the more food a patient eats, the less laxatives the patient will require) � With physical therapist, regarding exercise program � With physician, regarding mild analgesics and ointments for control of pain associated with bowel movements � With physician, regarding use of stool softeners, laxatives, suppositories, and enemas � With enterostomal therapist, regarding ostomy care (i.e., irrigations, stoma and skin care, and appliances) � With psychiatric nurse clinician, regarding counseling for the patient and family about possible underlying emotional components � With home health nurse, regarding follow-up planning for home and usual daily activities of living with emphasis on stress, etc. Child Health Nursing actions for Constipation in the child are the same as those for Adult Health. Modifications would be made for child’s age and size, for example, medication dosage and fluid amounts. For the diagnosis of Risk for Constipation, the following actions would be appropriate. ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributory factors including: Appropriate identification of cause of constipation in case of � Hirschsprung’s disease (congenital aganglionic megacolon) Hirschsprung’s disease will offer appropriate treatment. � Neonatal period: (1) Failure to pass meconium in first 24–48 h after birth (2) Reluctance to ingest fluids (3) Bile-stained vomitus (4) Abdominal distention (5) Intestinal obstruction � Infancy: (1) Inadequate weight gain (2) History of constipation (3) Abdominal distention (4) Episodic diarrhea and vomiting (5) Bloody diarrhea (6) Fever (7) Severe lethargy � Childhood: (1) Constipation (2) Ribbon-like, foul-smelling stools (3) Abdominal distention (4) Palpable fecal masses (5) History of poor appetite, poor growth • Monitor for contributing factors according to likelihood of Developmentally appropriate factors will assist in identification of potential for age, diet, known medical status, and likely essential issues. developmental crisis (e.g., iron in infant formula, vitamins, known hypothyroidism, self-toileting, etc.). Copyright © 2002 F.A. Davis Company CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 203 Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying lifestyle adjustments that may Provides information needed as basis for planning care and health be needed because of changes in physiologic function or needs maintenance. during experiential phases of life (e.g., pregnancy, postpartum, and after gynecologic surgery). • Teach the client changes that occur during pregnancy that Provides basic information for self-care during pregnancy, birthing contribute to decreased gastric motility and potential process, and postpartum. constipation: � Fluid intake may decrease because of nausea and vomiting of early pregnancy. � Increased use of mother’s body fluid intake to produce lactation can lead to decrease in fluid intake overall. � Supplemental iron during pregnancy can lead to severe constipation. � Fear of injury or pain upon defecation after birth can lead to constipation. • Teach anatomic shifting of abdominal contents because of fetal Provides information as a basis for nutrition plan during pregnancy. growth. Promotes self-care. • Teach hormonal influences (e.g., increased progesterone) on bodily functions: � Decreased stomach emptying time � Decreased peristalsis � Increase in water reabsorption � Decrease in exercise � Relaxation of abdominal muscles � Increase in flatulence • Teach the effects of the increase in oral iron

or calcium Provides basis for teaching the patient plan of self-care at home, and supplements on the gastrointestinal tract, e.g., constipation. promotes healing process. • Describe the physical changes present in the immediate postpartum period that affect the gastrointestinal tract: � Lax abdominal muscles � Fluid loss (perspiration, urine, lochia, or dehydration during labor and delivery) � Hunger • Assist the patient in planning diet that will promote healing, Promotes successful lactation, good self-care, and good nutrition, replace lost fluids, and help with return to normal bowel and provides basis for teaching care. evacuation. • Instruct in the use of ointments, anesthetic sprays, sitz baths, and witch hazel compresses to relieve episiotomy pain and reduce hemorrhoids. • Instruct in pelvic floor exercises (Kegel exercises) to assist healing and reduction of pain. • Teach nursing mothers alternate methods of assistance with bowel evacuation other than cathartics (cathartics are expressed in breast milk). � Prune juice � Hot liquids � High-fiber, high-roughage diet � Daily exercise • Describe the physical changes present in the immediate Provides basis for teaching and planning of care. Promotes and postoperative period (cesarean section and gynecologic surgery) encourages self-care. that affect the gastrointestinal tract: � Fluid loss (blood loss or dehydration as a result of NPO [nothing by mouth] status and surgery) � Decreased peristalsis � Bowel manipulation during surgery � Increased use of analgesics and anesthesia (continued) Copyright © 2002 F.A. Davis Company 204 ELIMINATION PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • During pregnancy: Gastrointestinal tract motility slows because of hormones � Encourage the woman to drink sufficient fluids (at least 8 (particularly progesterone) and increased growth of uterus. Greater glasses per day). absorption of water causes drying of stool. � Establish regular schedule for bowel movements. � Encourage balanced diet with appropriate amounts of fiber, fruits, and vegetables. Psychiatric Health The nursing actions for this diagnosis in Psychiatric Health are the same as those for Adult Health. Please refer to those recommended actions. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review medication record for drugs that may have constipation Older adults receiving antidepressants, anticholinergics, as a side effect. tranquilizers, or certain antacids may experience constipation due to the drug-delayed motility of waste matter through the intestine. Older adults are more likely to be on multiple medications that can result in constipation. • Collaborate with physician regarding changes in medication to avoid the side effect of constipation. Home Health NOTE: Adult Health actions are appropriate for Home Health. The locus of control shifts from the nurse to the client, family, or caregiver. ACTIONS/INTERVENTIONS RATIONALES • The nurse will teach others to complete activities. The client and members of the family may have different ideas regarding appropriate elimination patterns. • Teach the client and family the definition of constipation. Nursing interventions for physiologic definition are outlined in the Determine whether problem is perceived by the client and Adult Health nursing action. Nursing interventions for varying family because of incorrect definition or is based on physiologic definitions require family involvement. dysfunction. • Assist the client and family in identifying lifestyle changes that Home-based care requires involvement of the family. Bowel may be required: elimination problems may require adjustments in family activities. � Establishment of a regular elimination routine based on cultural and individual variations � Stress management techniques � Decrease in concentrated, refined foods � Identification of any food intolerances or allergies and avoidance of those foods � Appropriate use and frequency of use of prescribed and over-the-counter medications � Physiologic parameters of constipation Copyright © 2002 F.A. Davis Company CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 205 Constipation, Risk for, Actual, and Perceived FLOWCHART EVALUATION: EXPECTED OUTCOME Review the patient’s usual bowel elimination history. Compare to current habits. Has the patient returned to usual habits? Yes No Record data, e.g., has been Reassess using initial assessment factors. having soft, brown, well-formed stool every other day. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., having hard, formed bowel movements Did evaluation show another every 4 days; complains of problem had arisen? Yes anal pain. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 206 ELIMINATION PATTERN Diarrhea 2. Situational a. Alcohol abuse DEFINITION b. Toxins c. Laxative abuse Passage of loose, fluid, unformed stools.15 d. Radiation e. Tube feedings NANDA TAXONOMY: DOMAIN 3—ELIMINATION; f. Adverse effects of medication CLASS 2—GASTROINTESTINAL SYSTEM g. Contaminants h. Travel NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 3. Physiologic CLASS B—ELIMINATION MANAGEMENT a. Inflammation NOC: DOMAIN II—PHYSIOLOGIC HEALTH; b. Malabsorption CLASS F—ELIMINATION c. Infection process d. Irritation DEFINING CHARACTERISTICS15 e. Parasites 1. Hyperactive bowel sounds RELATED CLINICAL CONCERNS 2. At least 3 loose stools per day 3. Urgency 1. Inflammatory bowel disease (ulcerative colitis, Crohn’s disease, 4. Abdominal pain enteritis) 5. Cramping 2. Anemias 3. Gastric bypass or gastric partitioning surgery RELATED FACTORS15 4. Gastritis 1. Psychological a. High stress levels and anxiety HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Constipation Diarrhea may be secondary to present. The basic idea appears to be that the constipation. In instances of severe constipation amount of fluid ingested or absorbed by the body or impaction, semiliquid feces can leak around can affect the consistency of the fecal material. the areas of impaction and will appear to be Anxiety, Self-Esteem Disturbance, or Ineffective diarrhea. Individual Coping Any of these psychosocial Imbalanced Nutrition, Less Than Body diagnoses precipitate a stress response. Indices of Requirements If the individual is not ingesting stress include gastrointestinal signs and symptoms, enough food or sufficient bulk to allow feces to be including diarrhea, vomiting, and “butterflies” in well formed, diarrhea may well result. the stomach. Deficient Fluid Volume or Excess Fluid Volume Disturbed Sleep Pattern If a person’s biologic Although research has not definitely supported the clock is changed because of altered sleep-wake impact of fluid volume on bowel elimination, it is patterns, body responses attuned to the biologic a common practice to pay attention to these clock will also be altered. This includes usual diagnoses when either constipation or diarrhea is elimination patterns, and diarrhea may result. EXPECTED OUTCOME TARGET DATES Will return to usual bowel elimination habits by [date]. Target dates should be based on the individual’s usual bowel elim- ination habits. Thus, a target date 3 days from the day of admission would be reasonable for the majority of patients. Because diarrhea can be particularly life-threatening for infants and older adults, a target date of 2 days would not be too soon. Copyright © 2002 F.A. Davis Company DIARRHEA 207 NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Record amount, color, consistency, and odor following each Basic monitoring of conditioning as well as monitoring of bowel movement. effectiveness of therapy. • Monitor weight and electrolytes at least every 2 days while Monitors hydration status. diarrhea persists. [State dates here.] • Measure and total intake and output every shift. Monitors hydration status. • Decrease bowel stimulation through placing the patient on NPO Rests the bowel while maintaining fluid and electrolyte balance. status or clear liquid diet and intravenous hydration. Slowly reintroduce solid foods. • Place on enteric precautions until cause of diarrhea is Some types of diarrhea are infectious and are communicable. determined. • Make sure bathroom facilities are readily available. Helps prevent accidents and prevent embarrassment for the patient. • Administer antidiarrheal medications as ordered, and document Documents effectiveness of medication. results within 1 h after administration, e.g., Diarrhea decreased from 1 stool every 30 min to 1 stool every 2 h. • Increase fluid intake to at least 2500 mL per day. Maintains hydration status. • Offer fluids high in potassium and sodium at least once per hour, e.g., Gatorade, Pedialyte. • Serve fluids at tepid temperature (avoid temperature extremes such as very hot or very cold). • List the patient’s fluid likes and dislikes here. • Provide perineal skin care after each bowel movement. Monitor Dries moisture, prevents skin breakdown, and prevents perineal anal skin integrity at least once each shift. infection. • If tube feedings are causal factor, collaborate with physician Modifying any of the listed items may decrease incidence of diarrhea. regarding: � Infusion rate � Temperature of feeding � Dilution of feeding � Following feeding with water � Administration of Hydrocil at onset of tube feeding (increases stool consistency)18 • Provide room deodorizer, chlorophyll tablets, and fresh parsley Assists in elimination of odor; promotes pleasant environment. for the patient’s use. • Assist the patient with stress reduction exercises at least once Promotes relaxation and decreases stimulation of bowel. per shift; provide quiet, restful atmosphere. • Collaborate with dietitian regarding low-fiber, low-residue, Helps identify foods that stimulate bowel and exacerbate diarrhea. soft diet. • List here those foods that the patient has described as being irritating. • Teach the patient: Increases the patient’s knowledge of causes, treatment, and � Diet: avoiding irritating foods, including basic food pyramid complications of diarrhea. Promotes self-care. groups, influence of high-fiber foods, and influence of fruits. � Fluids: maintaining intake and output balance, influence of environmental temperature, influence of activity, and influence of caffeine and milk. � Medications: caution with over-the-counter medications, those that are antidiarrheal, and those that promote diarrhea, e.g., antacids. Copyright © 2002 F.A. Davis Company 208 ELIMINATION PATTERN Child Health ACTIONS/INTERVENTIONS RATIONALES • Weigh diapers for urine and stools, assess specific gravity after A strict assessment of intake and output serves as a basis for each voiding. monitoring the efficicacy of the treatment and may provide a database for treatment protocol. Hydration is monitored via specific gravity as an indication of the renal ability to adjust to fluid and electrolyte imbalance. • Monitor for sign and symptoms of dehydration: Dehydration is extremely dangerous for the infant and requires close � Depressed anterior fontanel in infants monitoring to offset the effects of dehydration. � Poor skin turgor � Decreased urinary output • Monitor signs and symptoms associated with bowel movement, Associated signs and symptoms serve as supportive data to follow including cramping, flatus, and crying. the altered bowel function, with an emphasis on related pain or discomfort. • Provide prompt and gentle cleansing after each diaper change. Skin breakdown occurs in a short period of time because of frequent For older children, offer warm soaks after each diarrheal bowel movements and the resultant skin irritation. episode. • Collaborate with physician regarding: These nursing measures constitute routine measures to monitor � Frequent stooling (more than 3 times per shift) diarrhea and its related problems. Prompt reporting and intervention � Excessive vomiting decrease the likelihood of more serious complications. � Possible dietary alterations for specific formula or diet � Monitoring electrolytes and renal function � Maintenance of IV fluids � Antidiarrheal medications Women’s Health NOTE: Some women experience diarrhea 1 or 2 days before labor begins. It is not certain why this oc- curs, but it is thought to be due to the irritation of the bowel by the contracting uterus and the de- crease in hormonal level (estrogen and progesterone) in late pregnancy. For diarrhea that is a precur- sor to labor, the following action applies. ACTIONS/INTERVENTIONS RATIONALES • Offer oral electrolyte solutions such as: Provides nutrition, electrolytes, and minerals that support a � Gatorade successful labor process. � Classic Coca-Cola � Jell-O � 10-K � Pedialyte Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client the role stress and anxiety play in this Diarrhea can be related to autonomic nervous system response to problem. emotions.19 • Develop with the client stress reduction plan and practice Promotes the client’s adaptive response to stress, and promotes the specific interventions 3 times a day at [list times here]. client’s sense of control. • Refer to Chapter 8 for specific nursing actions related to the diagnosis of Anxiety. Copyright © 2002 F.A. Davis Company DIARRHEA 209 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor medication intake to assess for potential side effect of The older adult may be having diarrhea as a result of antibiotic diarrhea. therapy, use of drugs with a laxative effect, such as magnesium- based antacids, or as a sign of drug toxicity secondary to antiarrhythmics such as digitalis, quinidine, or propranolol.

• Collaborate with physician regarding possible alterations in medications to decrease the problem of diarrhea. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family: Similar to Adult Health. For Home Health, the locus of control is � How to monitor perianal skin integrity now the client and family, not the nurse. � Techniques of perianal hygiene � Techniques of maintaining fluid and electrolyte balance (see Adult Health) � Administering antidiarrheal medications • Assist the client and family to set criteria to help them determine Provides the client and family background knowledge to seek when a physician or other intervention is required, e.g., child appropriate assistance as need arises. having more than 3 stools in 1 day. • Assist the client and family in identifying lifestyle changes that Behaviors to prevent recurrence of or continuation of the problem. may be required: � Avoid drinking local water when traveling in areas where water supply may be contaminated (foreign countries or streams and lakes when camping). � Practice stress management. � Avoid laxative or enema abuse. � Avoid foods that cause symptoms. � Avoid bingeing behavior. • Refer to appropriate assistive resources as indicated. Additional assistance may be required to maintain health. Use of readily available resources is cost-effective. • Educate the client in the importance of handwashing. To prevent the spread of microorganisms that may cause diarrhea. • Educate the client and caregivers about proper handling, To prevent the spread of microorganisms that may cause diarrhea. cooking, and storage of food. Copyright © 2002 F.A. Davis Company 210 ELIMINATION PATTERN Diarrhea FLOWCHART EVALUATION: EXPECTED OUTCOME Review the patient’s usual bowel elimination history. Compare to current pattern. Has the patient returned to usual bowel elimination pattern? Yes No Record data, e.g., has been Reassess using initial assessment factors. having one soft, formed brown stool daily for past 3 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., having 5 to 6 loose stools per day. Did evaluation show another Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company URINARY INCONTINENCE 211 Urinary Incontinence 2. Urinary frequency (more often than every 2 hours) 3. Urinary urgency DEFINITIONS15 E. Total Urinary Incontinence 1. Constant flow of urine occurring at unpredictable times Urinary Incontinence The state in which the individual experi- without distention, or uninhibited bladder contractions or ences a disturbance in urine elimination. spasms Functional Urinary Incontinence Inability of usually continent 2. Unsuccessful incontinence refractory treatments person to reach toilet in time to avoid unintentional loss of urine. 3. Nocturia 4. Lack of perineal or bladder-filling awareness Reflex Urinary Incontinence An involuntary loss of urine at some- 5. Unawareness of incontinence what predictable intervals when a specific bladder volume is reached. F. Urge Urinary Incontinence Stress Urinary Incontinence The state in which an individual ex- 1. Urinary urgency periences a loss of urine of less than 50 mL occurring with increased 2. Bladder contracture or spasm abdominal pressure. 3. Frequency (voiding more often than every 2 hours) Total Urinary Incontinence The state in which an individual ex- 4. Voiding in large amounts (more than 550 mL) periences a continuous and unpredictable loss of urine. 5. Voiding in small amounts (less than 100 mL) 6. Nocturia (more than 2 times per night) Urge Urinary Incontinence The state in which an individual ex- 7. Inability to reach toilet in time periences involuntary passage of urine occurring soon after a strong G. Risk for Urge Urinary Incontinence sense of urgency to void. 1. Effects of medication, caffeine, alcohol Risk for Urge Urinary Incontinence Risk for involuntary loss of 2. Detrusor hyperreflexia from cystitis, urethritis, tumor, renal urine associated with a sudden, strong sensation or urinary urgency. calculi, and central nervous system disorders above pontine micturition center NANDA TAXONOMY: DOMAIN 3—ELIMINATION; 3. Detrusor muscle instability with impaired contractibility CLASS 1—URINARY SYSTEM 4. Involuntary sphincter relaxation 5. Ineffective toileting habits NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 6. Small bladder capacity CLASS B—ELIMINATION MANAGEMENT NOC: DOMAIN II—PHYSIOLOGIC HEALTH; RELATED FACTORS15 CLASS F—ELIMINATION A. Urinary Incontinence 1. Urinary tract infection DEFINING CHARACTERISTICS15 2. Anatomic obstruction A. Urinary Incontinence 3. Multiple causality 1. Incontinence 4. Sensory motor impairment 2. Urgency B. Functional Urinary Incontinence 3. Nocturia 1. Psychological factors 4. Hesitancy 2. Impaired vision 5. Frequency 3. Impaired cognition 6. Dysuria 4. Neuromuscular limitations 7. Retention 5. Altered environmental factors B. Functional Urinary Incontinence 6. Weakened supporting pelvic structures 1. May only be incontinent in early morning C. Reflex Urinary Incontinence 2. Senses need to void 1. Tissue damage from radiation, cystitis, inflammatory bladder 3. Amount of time required to reach toilet exceeds length of conditions, or radical pelvic surgery time between sensing urge and uncontrolled voiding 2. Neurologic impairment above level of sacral micturition cen- 4. Loss of urine before reaching toilet ter or pontine micturition center 5. Able to completely empty bladder D. Stress Urinary Incontinence C. Reflex Urinary Incontinence 1. Weak pelvic muscles and structural supports 1. No sensation of urge to void 2. Overdistention between voidings 2. Complete emptying with lesion above pontine micturition 3. Incompetent bladder outlet center 4. Degenerative changes in pelvic muscles and structural sup- 3. Incomplete emptying with lesion above sacral micturition ports associated with increased age center 5. High intra-abdominal pressure (e.g., obesity, gravid uterus) 4. No sensation of bladder fullness E. Total Urinary Incontinence 5. Sensations associated with full bladder such as sweating, 1. Neuropathy preventing transmission of reflex indicating restlessness, and abdominal discomfort bladder fullness 6. Unable to cognitively inhibit or initiate voiding 2. Trauma or disease affecting spinal cord nerves 7. No sensation of voiding 3. Anatomic (fistula) 8. Predictable pattern of voiding 4. Independent contraction of detrusor reflex due to surgery 9. Sensation of urgency without voluntary inhibition of bladder 5. Neurologic dysfunction causing triggering of micturition at contraction unpredictable times D. Stress Urinary Incontinence F. Urge Urinary Incontinence 1. Reported or observed dribbling with increased abdominal 1. Alcohol pressure 2. Caffeine Copyright © 2002 F.A. Davis Company 212 ELIMINATION PATTERN 3. Decreased bladder capacity (for example, history of pelvic in- RELATED CLINICAL CONCERNS flammatory disease, abdominal surgeries, or indwelling uri- nary catheter) 1. Spinal cord injury 4. Increased fluids 2. Urinary tract infection 5. Increased urine concentration 3. Alzheimer’s disease 6. Irritation of bladder stretch receptors causing spasm (for ex- 4. Pregnancy ample, bladder infection) 5. Abdominal surgery 7. Overdistention of bladder 6. Prostate surgery G. Risk for Urge Urinary Incontinence The risk factors also serve as the Related Factors. HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Constipation Anything in the body that creates of a full bladder and by decreasing the person’s additional pressure on the bladder or bladder awareness of the sensation. sphincter may precipitate voiding. Constipation Impaired Physical Mobility As previously stated, can create this additional pressure because of the individual must be able to control the the increased amount of fecal material in the sphincter, walk a few steps, recognize and sigmoid colon and rectum. Incontinence may interpret that the bladder is full, and be able to then be a direct result of constipation or fecal indicate that he or she wants to go to the impaction. bathroom. Even if the person has some control of Excess Fluid Volume or Deficient Fluid Volume the sphincter and has correctly recognized and Because urination depends on input of the interpreted the cues of a full bladder, if he or she is stimulus that the bladder is full and because one of unable to get to the bathroom or get there in time the ways the body responds to excess fluid volume because of mobility problems, incontinence may is by increasing urinary output, the very fact that result. This may happen especially in a hospital. there is excess fluid volume may result in the Impaired Verbal Communication The ability to bladder’s inability to keep up with the kidney’s verbally communicate the need to urinate is production of urine. Thus, incontinence may important. If the person is unable to tell someone occur. Conversely, Deficient Fluid Volume can or have someone understand that he or she wants result in incontinence by eliminating the sensation to go to the bathroom, incontinence may occur. EXPECTED OUTCOME TARGET DATES Will remain continent at least 90 percent of the time by [date]. Treatment of incontinence requires training time and effort; there- fore, a target date 5 days from the date of admission would be rea- sonable to evaluate the patient’s progress toward meeting the ex- pected outcome. Additionally, there must be a realistic potential that urinary continence may be regained by the patient. For this reason, it would need to be qualified for use with handicapped or neurologically deficient clients according to the exact level of con- tinence hoped for. Copyright © 2002 F.A. Davis Company URINARY INCONTINENCE 213 NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Record: Monitors voiding pattern and effectiveness of treatment. � Time and amounts of each voiding � Whether voiding was continent or incontinent � The patient’s activity before and after incontinent incidence • Monitor, at least every 2 h on [odd/even] hour, for continence. Basic methods to monitor hydration, prevent tissue integrity problems, prevent infection, and promote comfort. • Monitor: � Weigh at least every 3 days � Laboratory values (e.g., electrolytes, WBC [white blood cells], or urinalyses) � For dependent edema � Intake and output, each shift � Perineal skin integrity at least once per shift � For bladder distention at least every 2 h on [odd/even] hour • Apply medicated ointment as ordered. • Use heat lamp as ordered. • Consult with enterstomal therapist regarding any stoma care. • Give sitz bath. • Respond immediately to the patient’s request for voiding. Immediate response may prevent an incontinent episode. • Schedule toileting: � Schedule at least 30 min before recorded incontinence times. � Awaken the patient once during night for voiding. Voiding at scheduled intervals prevents overdistention and helps establish a voiding pattern. � Encourage the patient to consciously hold urine to stretch bladder. � Teach biofeedback techniques. • Stimulate voiding at scheduled time by: � Assisting the patient to maintain normal anatomic position for voiding � Having the patient lightly brush inner thighs or lower abdomen � Running warm water over perineum (measure amount first) � Having the patient listen to dripping water � Placing the patient’s hands in warm water � Using Credé’s or Valsalva maneuver � Gently tapping over bladder � Drinking water while trying to void � Providing privacy � Providing night light and clear path to bathroom � Sitting on firm towel roll when incontinence threatens � Gradually increasing length of time, by 15 min, between voidings • Schedule fluid intake: Assists in predicting times of voiding. Decreases urge to void at � Avoid fluids containing caffeine and other fluids that produce unscheduled times. a diuretic effect (e.g., coffee, grapefruit juice, and alcohol). � Encourage 8 oz of fluid every 2 h on [odd/even] hour during the day. � Limit fluids after 6 p.m. • Maintain bowel elimination. Monitor bowel movements, and Fullness in bowel may exert pressure on bladder, causing bladder record at least once each shift. incontinence. • Beginning on day of admission, teach and have the patient Prevents skin irritation, infection, and odor. return-demonstrate perineal skin care. • Beginning on day of admission, guard and teach the patient to guard against nosocomial infection. • Assist the patient with stress reduction and relaxation techniques Promotes relaxation and self-control of voiding. at least once per shift. (continued) Copyright © 2002 F.A. Davis Company 214 ELIMINATION PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Collaborate with physician regarding: Prevents complications related to bladder overdistention. � Intermittent catheterization � Medications (e.g., urinary antiseptics, analgesics, or anticholinergics) • Collaborate with dietitian regarding food and fluids to acidify Decreases the probability of bladder infections. urine, e.g., cranberry juice or citrus fruits. • Collaborate with rehabilitation nurse clinician to establish a Allows establishment of a program that is current in content and bladder-retraining program. procedures. • Teach the patient exercises to strengthen pelvic floor muscles Strengthens pelvic floor muscles

to better control voiding. (10 times each at least 4 times per day) [state times here]: � Contracting posterior perineal muscles as if trying to stop a bowel movement � Contracting anterior perineal muscles as if trying to stop voiding � Starting and stopping urine stream � Bent-knee sit-ups � Bent-leg lifts • Teach the patient the importance of maintaining a daily routine: Helps establish urinary elimination pattern, and prevents � Voiding upon arising overdistention of bladder. � Awakening self once during the night � Voiding immediately before retiring � Not postponing voiding unnecessarily • Encourage the patient that he or she can be continent again, and Helps preserve self-concept and body image. Promotes compliance. encourage to avoid social isolation: � Wearing street clothes with protective pads in undergarments � Maintaining bladder-retraining program � Responding as soon as possible to voiding urge � Taking oral chlorophyll tablets � Losing weight if necessary • Refer to home health care agency for follow-up. Provides continuity of care and support system for ongoing care at home. • Consult with physician regarding medications20: � Vaginal or systemic hormonal therapy � Anticholinergic agents � Anticholinergic/antispasmodic agents • Monitor for side effects: � Dry mouth � Constipation � Blurred vision � Dizziness • Consult with physician about the use of weighted vaginal cones. The sensation of losing the cone from the vagina is believed to result They are worn in the vagina twice a day starting with 15 min at in an internal sensory biofeedback response, causing the pelvic floor a time. muscles to contract. Once a given cone can be retained easily for 15 to 30 min, the patient uses the next heavier one.20 • Use biofeedback techniques including electromyographic electrodes.21 • Consult with physician about the use of occlusive or “tampon- Mechanically blocks the leakage of urine by supporting the like” devices. urethrovesical junction or occluding the urethral meatus.20 Copyright © 2002 F.A. Davis Company URINARY INCONTINENCE 215 Child Health Nursing actions for the child with incontinence are the same as for Adult Health, with attention to the de - velopmental, anatomic, and physiologic parameters for age and with attention to organic potentials in - cluding congenital malformations. Special allowance for urinary reflux or recurrent potential urinary tract infections should be made in all ages. Women’s Health NOTE: This nursing diagnosis will pertain to the woman the same as to any other adult. During preg- nancy, the woman may occasionally experience uncontrolled voiding before reaching the toilet. This is usually caused by the overexpansion of the uterus or the pressure and weight of the baby and uterus on the bladder. This usually resolves after the delivery of the baby. Many women experience uncontrollable leakage of urine due to injury during pregnancy and childbirth. However, certain medications, such as diuretics, muscle relaxants, sedatives, and antidepressants, can contribute to urinary incontinence. ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying lifestyle adjustments that may be Bladder capacity is reduced because of enlarging uterus, needed to accommodate changing bladder capacity caused by displacement of abdominal contents by enlarged uterus, and anatomic changes of pregnancy. pressure on bladder by enlarged uterus. • Teach the patient: � To recognize symptoms of urinary tract infection (urgency, burning, or dysuria) � How to take temperature (make sure the patient knows how to read thermometer) � To seek immediate medical care if symptoms of urinary tract infection appear • Teach women Kegel exercises and pelvic floor musculature Strengthening of pelvic floor muscles helps reduce the urge to void retraining. and prevents leakage of urine. • Encourage good hygiene and cleansing of perineum, wiping from front to back to prevent urinary tract infections. • Discuss with health care provider the benefits of estrogen Loss of estrogen after menopause contributes to weakening of replacement therapy. pelvic muscle fibers. • Provide a nonjudgmental, relaxed atmosphere that will encourage the woman to ask questions without embarrassment. Psychiatric Health NOTE: If alteration is related to psychosocial issues and has no physiologic component, initiate the following nursing actions (refer to Adult Health for physiologically produced problems). ACTIONS/INTERVENTIONS RATIONALES • Monitor times, places, persons present, and emotional climate Identifies target behaviors, and establishes a baseline measurement around inappropriate voiding episodes. of behavior with possible reinforcers for inappropriate behavior.22 • Remind the client to void before a high-risk situation or remove Removes positive reinforcement for inappropriate behavior.23 secondary gain process from situation. • Provide the client with supplies necessary to facilitate Appropriate behavior cannot be implemented without the appropriate voiding behavior (e.g., urinal for the client in appropriate equipment. locked seclusion area). • Inform the client of acceptable times and places for voiding and Negative reinforcement eliminates or decreases behavior.23 of consequences for inappropriate voiding [note consequences here]. • Have the client assist with cleaning up any voiding that has Provides a negative consequence for inappropriate behavior.23 occurred in an inappropriate place. • Provide as little interaction with the client as possible during Lack of social response acts as negative reinforcement.22,23 cleanup. • Provide the client with positive reinforcement for voiding in Positive reinforcement encourages appropriate behavior.23 appropriate place and time [list specific reinforcers for this client here]. • Spend [number] min with the client every hour in an activity Interaction with the nurse can provide positive reinforcement. the client has identified as enjoyable; do not provide this time Withdrawing attention for inappropriate behavior provides negative or discontinue time if the client inappropriately voids during the reinforcement.23 specified time [list identified activities here]. (continued) Copyright © 2002 F.A. Davis Company 216 ELIMINATION PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • If the client voids inappropriately [number] times during a shift, Negative consequences decrease or eliminate undesirable behavior.23 he or she will spend [number] min (no more than 30) in time-out. Each inappropriate voiding in time-out adds 5 min to this time. • As behavior improves, add rewards for accumulated times of Intermittent reinforcement can render a response more resistant to appropriate voiding (e.g., on 2-h pass for 1 day of appropriate extinction once it has been established.24 voiding). Record these rewards here. NOTE: Refer to Chapters 8 and 11 for interventions related to the specific alterations that would promote this coping pattern. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review medication record for drugs such as sedatives, Sedatives and hypnotics may result in a delayed response to the hypnotics, or diuretics that may contribute to urinary urge to void. Diuretic therapy, depending on dosage and time of incontinence. administration, may result in an inability to reach the bathroom in a timely manner. Home Health NOTE: If this nursing diagnosis is made, it is imperative that a physician referral be made. If referred to home care under a physician’s care, it is important to maintain and evaluate response to prescribed treatments. ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying lifestyle changes that Basic measures to prevent recurrence. may be required: � Using proper perineal hygiene � Taking showers instead of tub baths � Drinking fluids to cause voiding every 2–3 h to flush out bacteria � Scheduling fluid intake � Voiding after intercourse � Avoiding perfumed soaps, toilet paper, or feminine hygiene sprays � Wearing cotton underwear � Using proper handwashing techniques � Following a daily routine of voiding (see Adult Health actions) � Establishing a bladder-retraining program � Doing exercises to strengthen pelvic floor muscles � Providing an environment conducive to continence � Wearing street clothes and protective underwear � Using an air purifier � Performing activities as tolerated � Providing unobstructed access to bathroom � Avoiding fluids that produce diuretic effect, e.g., caffeine, alcohol, or teas • Teach the client and family to dilute and acidify the urine by: Bacteria multiply rapidly in alkaline urine. � Increasing fluids � Introducing cranberry juice, poultry, etc. to increase acid ash • Teach the client and family to monitor and maintain skin Prevents or minimizes problems secondary to incontinence. integrity: � Keep skin clean and dry. � Keep bed linens and clothing clean and dry. � Use proper perineal hygiene. • Assist the client and family to set criteria to help them determine Assists in preventing or minimizing further physiologic damage. when a physician or other intervention is required, e.g., hema- turia, fever, or skin breakdown. • Monitor and teach importance of appropriate medications and treatments ordered by physician. (continued) Copyright © 2002 F.A. Davis Company URINARY INCONTINENCE 217 (continued) ACTIONS/INTERVENTIONS RATIONALES • Refer to appropriate assistive resources as indicated. Additional resources may be needed based on the underlying problem. • Educate the client about the importance of urinating on a Empties the bladder before stretching or distention occurs. regular basis, prior to urge. • Assist the client in obtaining necessary personal hygiene Provides a sense of security. supplies as needed (e.g., pads, diapers). • Educate the patient about prescribed medications and their Promotes sense of accountability and improves compliance. possible side effects. Copyright © 2002 F.A. Davis Company 218 ELIMINATION PATTERN Urinary Incontinence FLOWCHART EVALUATION: EXPECTED OUTCOME Review chart for past 48 hours. Calculate number of continent voidings and number of incontinent voidings. Determine percentage of continent voidings. Has the patient been continent 90% of the time? Yes No Record data, e.g., has been continent Reassess using initial assessment factors. last 18 of 20 voidings. Record RESOLVED. (May want to use CONTINUE until patient reaches as near to 100% continence as possible.) Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has been incontinent 10 out of 12 Did evaluation show another voidings. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company URINARY RETENTION 219 Urinary Retention RELATED CLINICAL CONCERNS DEFINITION 1. Benign prostatic hyperplasia 2. Hysterectomy The state in which the individual experiences incomplete emptying 3. Urinary tract infection of the bladder.15 4. Cancer NANDA TAXONOMY: DOMAIN 3—ELIMINATION; CLASS 1—URINARY SYSTEM HAVE YOU SELECTED NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; THE CORRECT DIAGNOSIS? CLASS B—ELIMINATION MANAGEMENT Urinary Incontinence Overflow incontinence NOC: DOMAIN II—PHYSIOLOGIC HEALTH; frequently occurs in patients whose primary CLASS F—ELIMINATION problem is really retention. The bladder is overdistended in retention, and some urine is DEFINING CHARACTERISTICS15 passed involuntarily because of the pressure of the retained urine on the bladder sphincter. 1. Bladder distention Self-Care Deficit, Toileting In neurogenic 2. Small, frequent voiding or absence of urine output bladder conditions, the bladder is chronically 3. Sensation of bladder fullness overdistended, resulting in urinary retention. 4. Dribbling 5. Residual urine 6. Dysuria EXPECTED OUTCOME 7. Overflow incontinence Will void under voluntary control and empty bladder at least every 4 hours by [date]. RELATED FACTORS15 1. High urethral pressure caused by weak detrusor TARGET DATES 2. Inhibition of reflex arc 3. Strong sphincter Urinary retention poses many dangers to the patient. An acceptable 4. Blockage target date to evaluate for lessening of retention would be within 24 to 48 hours after admission. NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor bladder for distention at least every 2 h on [odd/even] Monitors pattern and determines effectiveness of treatment; helps hour. prevent complications. • Measure and record intake and output each shift. Monitors fluid balance. • Maintain fluid intake: Ensures sufficient fluid intake, but restricts fluid when activity � Encourage fluids to at least 2000 mL per day. decreases. Assists in preventing nocturia. � Limit fluids after 6 p.m. • Monitor: Constipation may block bladder opening and lead to retention. � Bowel elimination at least once per shift Empty bowel facilitates free passage of urine. � Urinalysis, electrolytes, and weight at least every 3 days • Increase patient activity: Strengthens muscles and promotes kidney and bladder functioning. � Ambulate at least twice per shift while awake at [times]. � Collaborate with physical therapist, soon after admission, regarding an exercise program. • Collaborate with rehabilitation nurse clinician to initiate Allows establishment of a program that is current in content and bladder-retraining program. procedures. • Stimulate micturition reflex every 4 h while awake at [times]: Helps relax sphincter and strengthens voiding reflex. � Assist the patient to assume anatomically correct position for voiding. � Remind the patient to consciously be aware

of need-to-void sensations. (continued) Copyright © 2002 F.A. Davis Company 220 ELIMINATION PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach the patient to assist bladder contraction: � Credé’s maneuver � Valsalva maneuver � Abdominal muscle contraction • Beginning on day of admission, teach the patient the following Strengthens pelvic floor muscles. exercises: � Bent-knee sit-ups � Bent-leg lifts � Contracting posterior perineal muscles as if trying to stop a bowel movement � Contracting anterior perineal muscles as if trying to stop voiding � Starting and stopping urine stream • Collaborate with physician regarding: Relieves bladder distention, assists to schedule voiding, and � Intermittent catheterization prevents infection. � Medications (e.g., urinary antiseptics or analgesics) • Refer to home health agency at least 2 days prior to discharge Provides continuity of care and a support system for ongoing home for continued monitoring. care. Child Health NOTE: For infants and children less than 20 lb, it would be necessary to calculate exact intake and output and fluid requisites according to the etiologic factors present. Attention must be paid to the child’s physiologic developmental level regarding urinary control. ACTIONS/INTERVENTIONS RATIONALES • Provide opportunities for the child and parents to verbalize Assists in reducing anxiety, and attaches value to the patient’s and concerns or views about body image disturbances related to parents’ feelings. Promotes the development of a therapeutic urinary control and retention. Spend at least 30 min per shift in relationship. privacy with the child and parents to permit this verbalization. • Monitor parental (patient as applicable) knowledge of Parental knowledge will assist in the reduction of anxiety and will preventive health care for the patient: provide a greater likelihood for compliance with desired plan of care. � Teaching and observation of urinary catheterization � Maintenance of catheters and supplies � How to obtain supplies � How to obtain a sterile culture specimen � Appropriate restraint of the infant � Potential regarding urinary control • Provide opportunities for parental participation in the care of Appropriate parental involvement provides opportunities for trial the infant or child: care and allows the parents to practice care in a safe, supportive � Feedings environment prior to time of more total self-care. � Bathing � Monitoring intake and output � Planning for care to include individual preferences when possible � Assisting with procedures when appropriate � Provision of safety needs � Cautious handwashing to prevent infection � Appropriate emotional support � Appropriate diversional activity and relaxation � Need for pain medication • Collaborate with other health care professionals as needed. • Assist the family to identify support groups represented in the Identification of support for the family will best assist them to community for future needs. comply with the desired plan of care while reducing anxiety and promoting self-care. Copyright © 2002 F.A. Davis Company URINARY RETENTION 221 Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with physician regarding intermittent It is not easy to catheterize a woman post partum, nor is it desirable catheterization. to introduce an added risk of infection, so every effort and support should be directed toward helping the woman to void on her own. If, however, she is unable to void or to empty her bladder, an indwelling catheter may be placed for 24–48 h to rest the bladder and allow it to heal, edema to subside, and bladder and urethral tone to return.25 Psychiatric Health NOTE: Clients receiving antipsychotic and antidepressant drugs are at increased risk for this diagno- sis. Refer to Adult Health for general actions related to this diagnosis. ACTIONS/INTERVENTIONS RATIONALES • Place clients receiving antipsychotic or antidepressant Early intervention and treatment ensures better outcome. medication on daily assessment for this diagnosis. Elderly clients should be evaluated more frequently if their physical status indicates. • Monitor bladder for distention at least every 4 h at [times] if verbal reports are unreliable or if they indicate a voiding frequency greater than every 4 h. • Increase the client’s activity by: Activity maintains muscle strength necessary for maintenance of � Walking with the client [number] min 3 times a day at [list normal voiding patterns (see Adult Health for specific exercises to times here] strengthen pelvic floor muscles). � Collaborating with physical therapist regarding an exercise program � Placing the client in a room distant from the day area, nursing stations, and other activity if condition does not contraindicate this � Providing physical activities that the client indicates are of interest [list those here with the time for each] • Teach deep muscle relaxation, and spend 30 min twice a day at Anxiety can increase muscle tension and therefore contribute to [list times here] practicing this with the client. Associate urinary retention.23 relaxation with breathing so that the client can eventually relax with deep breathing while attempting to void. • Collaborate with physician regarding catheterization and Catheterization increases the risk for infection, so every effort and medication adjustments. support should be directed toward helping the client to void on his or her own. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review medication record for use of antidepressant and The use of antidepressant and antipsychotic medication can result antipsychotic medications. in urinary retention as a side effect. Copyright © 2002 F.A. Davis Company 222 ELIMINATION PATTERN Home Health NOTE: If this nursing diagnosis is made, it is imperative that physician referral be made. Vigorous in- tervention is required to prevent damage or systemic infection. If referred to home care under physi- cian’s care, it is important to maintain and evaluate response to prescribed treatments. ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in lifestyle changes that may be Similar to Adult Health. Locus of control now is with the family and required: client. � Monitor bladder for distention. � Record intake and output. � Stimulate micturition reflex (see Adult Health). � Institute bladder-retraining program. � Perform exercises to strengthen pelvic floor muscles. � Use proper position for voiding. � Maintain fluid intake. � Maintain physical activity as tolerated. � Use straight catheterization. • Assist the client and family to set criteria to help them determine Knowledge will assist the client and family to seek timely when a physician or other intervention is required, e.g., interventions. specified intake and output limit, pain, or bladder distention. • Monitor and teach importance of appropriate medications and Provides the client and family with knowledge to care for problem. treatments ordered by physician. • Refer to appropriate assistive resources as indicated. Additional support may be required to help the client and family maintain care at home. Copyright © 2002 F.A. Davis Company URINARY RETENTION 223 Urinary Retention FLOWCHART EVALUATION: EXPECTED OUTCOME Review chart for past 48 hours. Interview the patient. Is the patient voiding under voluntary control? Yes No Does patient have sensation that bladder is being emptied? (May need to check with physician No Reassess using initial assessment factors. regarding catheterization to check residual amounts.) Yes No Is diagnosis validated? Record data, e.g., chart indicates voiding every 4 to 5 hours in amounts Record new assessment data. from 450–600 mL. Patient Record REVISE. Add new states, “feel emptying bladder.” diagnosis, expected outcome, Record RESOLVED. Delete target date, and nursing actions. Yes nursing diagnosis, expected Delete invalidated diagnosis. outcome, target date, and nursing actions. Start new evaluation process. Record data, e.g., has had four episodes of catheterization Did evaluation show another in past 30 hours. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 5 Activity-Exercise Pattern 1. ACTIVITY INTOLERANCE, RISK FOR 14. HOME MAINTENANCE, AND ACTUAL 231 IMPAIRED 308 2. AIRWAY CLEARANCE, 15. INFANT BEHAVIOR, DISORGANIZED, INEFFECTIVE 239 RISK FOR AND ACTUAL, AND 3. AUTONOMIC DYSREFLEXIA, RISK FOR READINESS FOR ENHANCED AND ACTUAL 246 ORGANIZED 313 4. BED MOBILITY, IMPAIRED 251 16. PERIPHERAL NEUROVASCULAR 5. BREATHING PATTERN, DYSFUNCTION, RISK FOR 318 INEFFECTIVE 256 17. PHYSICAL MOBILITY, 6. CARDIAC OUTPUT, IMPAIRED 322 DECREASED 262 18. SELF-CARE DEFICIT (FEEDING, 7. DISUSE SYNDROME, RISK BATHING-HYGIENE, DRESSING- FOR 270 GROOMING, TOILETING) 330 8. DIVERSIONAL ACTIVITY, 19. SPONTANEOUS VENTILATION, DEFICIENT 275 IMPAIRED 337 9. DYSFUNCTIONAL VENTILATORY 20. TISSUE PERFUSION, INEFFECTIVE WEANING RESPONSE (SPECIFY TYPE: RENAL, (DVWR) 280 CEREBRAL, CARDIOPULMONARY, 10. FALLS, RISK FOR 285 GASTROINTESTINAL, 11. FATIGUE 289 PERIPHERAL) 341 12. GAS EXCHANGE, IMPAIRED 294 21. TRANSFER ABILITY, IMPAIRED 350 13. GROWTH AND DEVELOPMENT, 22. WALKING, IMPAIRED 356 DELAYED; DISPROPORTIONATE 23. WANDERING 360 GROWTH, RISK FOR; AND DELAYED 24. WHEELCHAIR MOBILITY, DEVELOPMENT, RISK FOR 301 IMPAIRED 364 Pattern Description other functional pattern. Any admission to a hospital may pro- mote the development of problems in this area because of the This pattern focuses on the activities of daily living (ADLs) and the therapeutics required for the medical diagnosis (e.g., bedrest) or amount of energy the individual has available to support these ac- because of agency rules and regulations (e.g., limited visiting tivities. The ADLs include all aspects of maintaining self-care and hours). incorporate leisure time as well. Because the individual’s energy level and mobility for ADLs are affected by the proper functioning of the neuromuscular, cardiovascular, and respiratory systems, Pattern Assessment nursing diagnoses related to dysfunctions in these systems are in- cluded. 1. Does the patient’s heart rate or blood pressure increase abnor- As with the other patterns, a problem in the activity-exercise mally in response to activity? pattern may be the primary reason for the patient’s entering a. Yes (Activity Intolerance) the health care system or may arise secondary to problems in an- b. No 224 Copyright © 2002 F.A. Davis Company PATTERN DESCRIPTION 225 2. Does the patient have dyspnea after activity? 21. Does the patient have full range of motion? a. Yes (Activity Intolerance) a. Yes b. No b. No (Impaired Physical Mobility or Impaired Walking) 3. Does the patient have a medical diagnosis related to the car- 22. Does the patient have problems moving self in bed? diovascular or respiratory system? a. Yes (Impaired Bed Mobility) a. Yes (Risk for Activity Intolerance) b. No b. No 23. Does the patient have problems ambulating? 4. Does the patient have a history of Activity Intolerance? a. Yes (Impaired Physical Mobility or Impaired Walking) a. Yes (Risk for Activity Intolerance) b. No b. No 24. Is the patient paralyzed? 5. Does the patient complain of fatigue, weakness, or lack of a. Yes (Risk for Disuse Syndrome) energy? b. No a. Yes (Activity Intolerance or Fatigue) 25. Is the patient immobilized by casts or traction? b. No a. Yes (Risk for Disuse Syndrome or Risk for Peripheral 6. Is the patient unable to maintain usual routines? Neurovascular Dysfunction) a. Yes (Fatigue or Self-Care Deficit) b. No b. No 26. Does the patient have a spinal cord injury at T7 or above? 7. Does the patient report difficulty in concentrating? a. Yes (Risk for Autonomic Dysreflexia) a. Yes (Fatigue) b. No b. No 27. Does the patient have a spinal cord injury at T7 or above and 8. Review self-care chart. Does the patient have any self-care paroxysmal hypertension? deficits? a. Yes (Autonomic Dysreflexia) a. Yes (Self-Care Deficit [specify which area]) b. No b. No 28. Does the patient have a spinal cord injury at T7 or above and 9. Can the patient engage in usual hobby while in hospital? bradycardia or tachycardia? a. Yes a. Yes (Autonomic Dysreflexia) b. No (Deficient Diversional Activity) b. No 10. Does the family need help with home maintenance after the 29. Review mental status examination. Is the patient exhibiting patient goes home? confusion or drowsiness? a. Yes (Impaired Home Maintenance) a. Yes (Impaired Gas Exchange) b. No b. No 11. Does the patient have insurance? 30. Review blood gases. Does the patient demonstrate hypercapnia? a. Yes a. Yes (Impaired Gas Exchange or Impaired Spontaneous Ven- b. No (Impaired Home Maintenance) tilation) 12. Is the patient within height and weight norm for age? b. No a. Yes 31. Were rales (crackles) or rhonchi (wheezes) present on chest b. No (Delayed Growth and Development) auscultation? 13. Can the patient perform developmental skills appropriate for a. Yes (Ineffective Airway Clearance) age level? b. No a. Yes 32. Is respiratory rate increased above normal range? b. No (Delayed Growth and Development) a. Yes (Ineffective Airway Clearance or Ineffective Breathing 14. Are there any abnormal movements? Pattern) a. Yes (Disorganized Infant Behavior) b. No b. No 33. Is the patient on

a ventilator? If yes, does the patient have rest- 15. Does the infant respond appropriately to stimuli? lessness or an increase from baseline of blood pressure, pulse, a. Yes or respiration when attempts at weaning are tried? b. No (Disorganized Infant Behavior) a. Yes (Dysfunctional Ventilatory Weaning Response) 16. Does the patient’s cardiogram indicate arrhythmias? b. No a. Yes (Decreased Cardiac Output) 34. Does the patient have dyspnea and shortness of breath? b. No a. Yes (Ineffective Breathing Pattern, Impaired Spontaneous 17. Is the patient’s jugular vein distended? Ventilation, or Activity Intolerance) a. Yes (Decreased Cardiac Output) b. No b. No 35. Is the patient exhibiting pursed-lip breathing? 18. Are the patient’s peripheral pulses within normal limits? a. Yes (Ineffective Breathing Pattern) a. Yes b. No b. No (Decreased Cardiac Output, Ineffective Tissue Perfu- 36. Does the patient have a history of falling? sion, or Risk for Peripheral Neurovascular Dysfunction) a. Yes (Risk for Falls) 19. Are the patient’s extremities cold? b. No a. Yes (Ineffective Tissue Perfusion or Risk for Peripheral 37. Does the patient have diminished mental status? Neurovascular Dysfunction) a. Yes (Risk for Falls) b. No b. No 20. Does the patient have claudication? 38. Does the patient have difficulty in manipulating his or her a. Yes (Ineffective Tissue Perfusion or Risk for Peripheral wheelchair? Neurovascular Dysfunction) a. Yes (Impaired Wheelchair Mobility) b. No b. No Copyright © 2002 F.A. Davis Company 226 ACTIVITY-EXERCISE PATTERN 39. Can the patient independently transfer himself or herself from the cardiovascular system that prevents large shifts in blood vol- site to site? ume does not adequately function. When the individual who a. Yes has experienced extended bedrest attempts to assume an upright b. No (Impaired Transfer Ability) position, gravity pulls an excessive amount of blood volume to the feet and legs, depriving the brain of adequate oxygen. As a Conceptual Information result, the individual experiences orthostatic hypotension.4 3. Musculoskeletal: Inactivity causes decreased bone stress and de- There are several nursing diagnoses included in this pattern that, at creased muscle tension. Osteoblastic and osteoclastic activities be- first glance, seem to have little relationship with each other. How- come imbalanced, leading to calcium and phosphorus loss. De- ever, closer investigation demonstrates that there is one concept creased muscle use leads to decreased muscle mass and strength common to all of the diagnoses: immobility. Immobility or the im- as a result of infrequent muscle contractions and protein loss. pulses that control and coordinate mobility can contribute to the 4. Metabolic: Basal metabolic rate and oxygen consumption de- development of any of these diagnoses, or any of these diagnoses crease, leading to decreased efficiency in using nutrients to build can ultimately lead to the development of immobility. new tissues. Normally, body tissues break down nitrogen, but Mobility and immobility are end points on a continuum with apparently muscle mass loss with accompanying protein loss many degrees of impaired mobility or partial mobility between the leads to nitrogen loss and a negative nitrogen balance. Changes two points.1 Immobility is usually distinguished from impaired mo- in tissue metabolism lead to increased potassium and calcium bility by the permanence of the limitation. A person who is quadri- excretion. Decreased energy use and decreased basal metabolic plegic has immobility, because it is permanent; a person with a long rate (BMR) lead to appetite loss, which leads to decreased nutri- cast on the left leg has impaired mobility, because it is temporary.2 ent intake necessary to offset losses. Mobility is defined as the ability to move freely and is one of the 5. Skin: The negative nitrogen balance previously discussed, cou- major means by which we define and express ourselves. The cen- pled with continuous pressure on bony prominences, leads to a tral nervous system integrates the stimuli from sensory receptor greatly increased potential for skin breakdown. nerves of the peripheral nervous system and projection tracts of the Immobility is not the sole causative factor of the nursing diag- central nervous system to respond to the internal or external envi- noses in this pattern. Many of the diagnoses can be related to spe- ronment of the individual. This integration allows for movement cific medical diagnoses, such as congestive heart failure, or may oc- and expressions. A problem with mobility can be a measure of the degree of illness or health problem an individual has.3 cur as a result of diagnoses in this pattern, for example, Delayed Growth and Development. However, the concept of immobility Patients with self-care deficits are most often those who are ex- does serve to point out the interrelatedness of the diagnoses. periencing some type of mobility problem.2 The problem with mo- Because fatigue plays a major role in determining the quality and bility requires greater energy expenditure, which leads to activity amount of musculoskeletal activity undertaken, consideration of the intolerance, deficient diversional activity, and impaired home factors that influence fatigue is an essential part of nursing assessment maintenance simply because of the lack of energy or nervous sys- for the activity-exercise pattern. Fatigue might be considered in two tem response to engage in these activities. general categories: experiential and muscular. The degree to which Problems with mobility and nervous system response also lead to the individual participates in activity is significant in determining the other physical problems. When a person has impaired mobility or fatigue experienced. Activities that the individual enjoys are less immobility, bedrest is quite often prescribed or is voluntarily sought likely to produce fatigue than are those not enjoyed. Preferences in an effort to conserve energy. Several authors3–5 describe the phys- should be considered within the framework of capacity and needs. ical problems that can occur secondary to prolonged bedrest: Obviously, other factors that must be considered include the physi- 1. Respiratory: Decreased chest and lung expansion causes slower cal and medical condition of the person and his or her emotional and more shallow respiration. Pooling of secretions occurs sec- state, level of growth and development, and state of health in general. ondary to decreased respiratory effort and the effects of gravity. Oxygenation needs and extrinsic factors would also need to be ad- The cough reflex is decreased as a result of decreased respiratory dressed. If there is overstimulation as with noise, extremes of tem- effort, gravity, and decreased muscle strength. Acid-base bal- perature, or interruption of routines, a greater amount of fatigue or ance is shifted, causing a retention of carbon dioxide. Respira- disorganized behavior can be expected. Sensory understimulation tory acidosis causes changes in mentation: vasodilation of cere- with resultant boredom can also contribute to fatigue. brovascular blood vessels and increased cerebral blood flow, Fatigue can develop as a result of too much waste material accu- headache, mental cloudiness, disorientation, dizziness, general- mulating and too little nourishment going to the muscles. Muscle ized weakness, convulsions, and unconsciousness. Additionally, fatigue usually is attributed to the accumulation of too much lactic because of the buildup of carbon dioxide in the lungs, adequate acid in the muscles. Certain metabolic conditions, such as conges- oxygen cannot be inspired, leading to tissue hypoxia. tive heart failure, place a person at greater risk for fatigue. 2. Cardiovascular: Circulatory stasis is caused by vasodilation and impaired venous return. Muscular inactivity leads to vein dila- Developmental Considerations tion in dependent parts. Gravity effects also occur. Decreased respiratory effort and gravity lead to decreased thoracic and ab- Diet, musculoskeletal factors, and respiratory and cardiovascular dominal pressures that usually assist in promoting blood return mechanisms influence activity. Developmental considerations for to the heart. Quite often patients have increased use of the Val- diet are addressed in Chapter 3. The developmental considerations salva maneuver, which leads to increases in preload and after- discussed here specifically relate to musculoskeletal, respiratory, load of cardiac output and ultimately a decreased cardiac out- and cardiovascular factors. put. Continued limitation of activity leads to decreased cardiac rate, circulatory volume, and arterial pressure as a result of re- INFANT distribution of body fluids. Venous stasis contributes to the po- tential for deep venous thrombosis and pulmonary embolus. Af- Many things, including genetic, biologic, and cultural factors, in- ter prolonged bedrest, the normal neurovascular mechanism of fluence physical and motor abilities. Nutrition, maturation of the Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 227 central nervous system, skeletal formation, overall physical health show an acid-base imbalance. The rate and rhythm of respiration status, amount of stimulation, environmental conditions, and con- in the infant is somewhat irregular, and it is not unusual for the in- sistent loving care also play a part in physical and motor abilities.6 fant to use accessory muscles of respiration. Retractions with respi- Girls usually develop more rapidly than do boys, although the ac- ration are common. tivity level is higher in boys.6 The alveoli of the infant increase in number and complexity very All muscular tissue is formed at birth, but growth occurs as the rapidly. By 1 year of age, the alveoli and the lining of the air pas- infant uses the various muscle groups. This use stimulates increased sages have matured considerably. strength and function. Respiratory tract obstructions are common in this age group be- The infant engages in various types of play activity at various cause of the short trachea and the almost straight-line position of times in infancy because of developing skills and changing needs. the right main stem bronchus. Additionally, the epiglottis does not The infant needs the stimulation of parents in this play activity to effectively close over the trachea during swallowing. Thus, foreign fully develop. However, parents should be aware of the dangers in objects are aspirated into the lungs. overstimulation. Fatigue, inattention, and injury to the infant may In terms of cardiovascular development, the foramen ovale result.6 closes during the first 24 hours, and the ductus arteriosus closes af- Interruptions in the normal developmental sequence of play ac- ter several days. The neonate can survive mild oxygen deprivation tivities due to illness or hospitalization, for example, can have a longer than an adult. The Apgar scoring system is used to measure detrimental effect on the future development of the infant or child. the physical status of the newborn and includes heart rate, color, An understanding of the normal sequence of play development is and respiration. There is no day-night rhythm to the neonate’s heart important so that therapeutic interventions can be designed to ap- rate, but from the sixth week on, the rate is lower at night than dur- proximate the developmental needs of the individual. ing the day. Axillary temperature readings and age-sized blood The structural description of play development focuses on the Pi- pressure cuffs should be used to assess vital signs. The pulse is 120 agetian concepts of the increasing cognitive complexity of play ac- to 150 beats per minute; respiration ranges from 35 to 50 per tivities. Elementary sensorimotor-based games emerge first, with minute; and blood pressure ranges from 40 to 90 mm Hg systolic the gradual development of advanced social games in adulthood.7 and 6 to 20 mm Hg diastolic. Vital signs become more stable over Play activities assist in the child’s development of psychomotor the first year. Listening for murmurs should be done over the base skills and cognitive development. Socialization skills are learned and of the heart rather than at the apex. Breath sounds are bron- practiced via the interaction with others during play. As the child chovesicular. The neonate has limited ability to respond to envi- begins to learn more about his or her body during play, he or she ronmental temperature changes and loses heat rapidly. This leads will incorporate more complicated gross and fine motor skills. Play to an increased basal metabolic rate (BMR) and an increased work- is extremely valuable in the development of language and other load on the heart. Until age 7, the apex is palpated at the fourth in- communication skills. Play helps the individual establish control terspace just to the left of the midclavicular line. over self and the environment and provides a sense of accomplish- ment. Through play activities, the infant learns to trust the environ- TODDLER AND PRESCHOOLER ment. Play also affords the child the opportunity to express emo- tions that would be unacceptable in other normal social situations. By this age, the child is walking, running, climbing,

and jumping. Practice games begin during the sensorimotor level of cognitive The toddler is very active and very curious. He or she gets into development at 1 to 4 months of age and continue with increasing everything. This helps the toddler organize his or her world and de- complexity throughout childhood. These games include skills that velop spatial and sensory perception.6 It is during this period that are performed for the pleasure of functioning, that is, for the plea- the child begins to see himself or herself as a person separate from sure of practice. his or her parents and the environment. This increasing level of au- Symbolic games appear later during the sensorimotor period tonomy also presents a challenge for the caregivers. The child al- than do practice games—at about age 12 to 18 months. Make- ternates between the security of the parents and the exciting explo- believe is now added to the practice game. Other objects represent ration of the environment. elements of absent objects or persons. As previously stated, activity The toddler is fairly clumsy, but gross and fine motor coordination is influenced by respiratory and cardiovascular mechanisms. is improving. Neuromuscular maturation and repetition of move- The respiratory mechanisms, or air-conducting passages (the ments help the child further develop skills.6 Muscles grow faster than nose, pharynx, larynx, trachea, bronchi, bronchioles, and alveoli) bones during these years. Safety is a major concern for children of and lungs, of the infant are small, delicate, and immature. The air this age. The toddler, especially, wants to do many things for himself that enters the nose is cool, dry, and unfiltered. The nose is unable or herself, thus testing control of self and the environment. to filter the air, and the mucous membranes of the upper respira- tory tract are unable to produce enough mucus to humidify or Bathing and Hygiene warm the inhaled air. Therefore, the infant is more susceptible to respiratory tract infections.7 By the age of 3, the child can wash and dry his or her hands with Additionally, the infant is a nose breather. When upper respira- some wetting of clothes and can brush his or her teeth, but requires tory tract infections do occur, the infant is unable to appropriately assistance to perform the task adequately. By the fourth birthday, clear the airways and may get into some difficulty until he or she the child may bathe himself or herself with assistance. The child learns to breathe through his or her mouth (at about 3 to 4 months will be able to bathe himself or herself without assistance by the age of age). The cough of the infant is not very effective, and the infant of 5. Both parents and nurses must keep in mind the safety issues quickly becomes fatigued with the effort.7 involved in bathing; the child requires supervision in selection of In the lungs, the alveoli are functioning, but not all alveoli may water temperature and in the prevention of drowning. be expanded. Therefore, there is a large amount of dead space in the lungs. The infant has to work harder to exchange enough oxy- Dressing and Grooming gen and carbon dioxide to meet body demands. The elevated res- piratory rate of the infant (30 to 60 per minute) reflects this in- At age 18 to 20 months, the child has the fine motor skills required creased work. Additionally, arterial blood gases of the infant may to unzip a large zipper. By 24 to 48 months, the child can unbut- Copyright © 2002 F.A. Davis Company 228 ACTIVITY-EXERCISE PATTERN ton large buttons. The child can put on a coat with assistance by 100 mm Hg systolic and 60 to 64 mm Hg diastolic. The size of the age 2; the child can undress himself or herself in most situations vascular bed increases in the toddler, thus reducing resistance to and can put on his or her own coat without assistance by age 3. At flow. The capillary bed has increased ability to respond to environ- 31⁄2 years, the child can unbutton small buttons, and by 4 years, can mental temperature changes. Lung volume increases. Breath sounds button small buttons. Dressing without assistance and beginning are more intense and more bronchial, and expiration is more pro- ability to lace shoes are accomplishments of the 5-year-old. The de- nounced. The toddler’s chest should be examined with the child in velopment of fine motor skills is required for most of the tasks of an erect position, then recumbent, and then turned to the left side. dressing. It is important that the child’s clothing have fasteners that Arrhythmias and extrasystoles are not uncommon but should be are appropriate for the motor skill development. The child will re- recorded. quire assistance with deciding the appropriateness of clothing se- The temperature of the preschooler is 98.6 F  1 (orally); pulse lected; seasonal variations in weather and culturally accepted ranges from 80 to 100 beats per minute; respiration is 30 per norms regarding dressing and grooming are learned by the child minute  5; and blood pressure is 90/60 mm Hg  15. There is with assistance. continued increase of the vascular bed, lung volume, and so on, in keeping with physical growth. Feeding SCHOOL-AGE CHILD The child can drink from a cup without much spilling by 18 months. The child will have frequent spills while trying to get the Whereas the muscles were growing faster than the bones during the contents of a spoon into his or her mouth at this age. By 2 years of toddler and preschool years, the skeletal system is growing rapidly age, the child can drink from a cup; use of the spoon has improved during these years—faster than the muscles are growing. Children at this age, but the child will still spill liquids (soup) from a spoon may experience “growing pains” because of the growth of the long when eating. The child can eat from a spoon without spilling by 31⁄2 bones. There is a gradual increase in muscle mass and strength, and years. Accomplished use of the fork occurs at 5 years. the body takes on a leaner appearance. The child loses his or her “baby fat,” muscle tone increases, and loose movements disappear. Toileting Adequate exercise is needed to maintain strength, flexibility, and balance and to encourage muscular development.7 Males have a By age 3, the child can go to the toilet without assistance; the child greater number of muscle cells than females. Posture becomes more can pull pants up and down for toileting without assistance at this upright and straighter but is not necessarily influenced by exercise. stage as well. The development of food preferences, preferred eat- Posture is a function of the strength of the back muscles and the ing schedules and environment, and toileting behavior are im- general state of health of the child. Poor posture may be reflective parted to the child by learning. Toileting, food, and the eating expe- of fatigue as well as skeletal defects,7 with fatigue being exhibited rience may also include pleasures, control issues, and learning tasks by such behaviors as quarrelsomeness, crying, or lack of interest in in addition to the development of the motor skills required to ac- eating. Skeletal defects such as scoliosis begin to appear during this complish the task. Delays or regressions in the tasks of self-feeding period. may reflect issues other than a self-care deficit, for example, disci- Neuromuscular coordination is sufficient to permit the school- pline, family coping, and role-relationships. age child to learn most skills6; however, care should be taken to prevent muscle injuries. Hands and fingers manipulate things well. Physiology Although children age 7 have a high energy level, they also have an increased attention span and cognitive skills. Therefore, they tend During the preschool years, the child seems to have an unlimited to engage in quiet games as well as active ones. Seven-year-olds supply of energy. However, he or she does not know when to stop tend to be more directed in their range of activities. Games with and may continue activities past the point of exhaustion. Parents rules develop as the child engages in more social contacts. These should provide a variety of activities for the age groups, as the at- games characteristically emerge during the operational phase of tention span is short. cognitive development in the school-age child. These rule games The lung size and volume of the toddler have now increased, and may also be practice or symbolic in nature, but now the child at- thus the oxygen capacity of the toddler has increased. The toddler taches social significance and order to the play by imposing the is still susceptible to respiratory tract infections but not to the ex- structure of rules. tent of the infant. The rate and rhythm of respiration have de- Eight-year-olds have grace and balance. Nine-year-olds move creased, and respirations average 25 to 35 per minute. Accessory with less restlessness; their strength and endurance increase; and muscles of respiration are infrequently used now, and respiration their hand-eye coordination is good.6 Competition, among peers is is primarily diaphragmatic. important to test out their strength, agility, and coordination. Al- The respiratory structures (trachea and bronchi) are positioned though 10- to 12-year-old children are better able to control and farther down in the chest now, and the epiglottis is effective in clos- direct their high energy level, they do have energetic, active, rest- ing off the trachea during swallowing. Thus, aspiration and airway less movements with tension release through finger drumming, obstruction are reduced in this age group. foot tapping, or leg swinging. The respiratory rate of the preschooler is about 30 per minute. The respiratory rate of the school-age child slows to 18 to 22 per The preschooler is still susceptible to upper respiratory tract infec- minute. The respiratory tissues reach adult maturity, lung volume tions. The lymphatic tissues of the tonsils and adenoids are in- increases, and the lung capacity is proportionate to body size. The volved in these respiratory tract infections. Tonsillectomies and school-age child is still susceptible to respiratory tract infections. adenoidectomies are not performed “routinely” any more. These The frontal sinuses are fairly well developed by this age, and all the tissues serve to protect the respiratory tract, and valid reasons must mucous membranes are very vulnerable to congestion and inflam- be presented to warrant their removal. mation. The temperature, pulse, and respiration of the school-age The temperature of the toddler ranges around 99F  1 (orally); child are gradually approaching adult norms, with temperature pulse ranges around 105 beats per minute  35; respirations range ranging from 98 to 98.6F, pulse (resting) 60 to 70 beats per from 20 to 35 per minute; and blood pressure ranges from 80 to minute, and respiration from 18 to 20 per minute. Systolic blood Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 229 pressure ranges from 94 to 112 mm Hg, and diastolic from 56 to reaches its peak of physiologic resilience during late adolescence 60 mm Hg. The heart grows more slowly during this period and is and young adulthood. Regular physical training and an individual- smaller in relation to the rest of the body. Because the heart must ized conditioning program can increase both strength and tolerance continue to supply the metabolic needs, the child should be advised to strenuous activity. against sustained physical activity and be watched for tiring. After Faulty nutrition is another major cause of fatigue in the adoles- age 7, the apex of the heart lies at the interspace of the fifth rib at cent. Poor eating habits established during the school-age years, the midclavicular line. Circulatory functions reach adult capacity. combined with the typical quick-service, quick-energy food con- The child will still have some vasomotor instability with rapid va- sumption patterns of adolescents, frequently lead to anemia, which sodilation. A third heart sound and sinus arrhythmias are fairly in itself can lead to activity intolerance.7 common but, again, should be recorded. The adolescent may be given responsibility for assisting with the maintenance of the family home, or may be responsible for his or ADOLESCENT her own home if living independent from the family of origin. The role exploration characteristic of adolescence may lead to tempo- Growth

in skeletal size, muscle mass, adipose tissue, and skin is rary changes in hygiene practices. significant in adolescence. The skeletal system grows faster than the Recreational activities in adolescence often take the form of or- muscles; thus, stress fractures may result. The large muscles grow ganized sports and other competitive activities. Social relationships faster than the smaller muscles, with the occasional result of poor are developed and enhanced, specific motor and cognitive skills re- posture and decreased coordination. Boys are clumsier than girls. lated to a specific sport are refined, and a sense of mastery can be Muscle growth continues in boys during late adolescence because developed. Group activities and peer approval and acceptance are of androgen production.6 important. The adolescent responds to peer activities and experi- Physical activities provide a way for adolescents to enjoy the ments with different roles and lifestyles. The nurse must distinguish stimulation of conflict in a socially acceptable way. Some form of self-care practices that are acceptable to the peer group from those physical activity should be encouraged to promote physical devel- that indicate a self-care deficit. opment, prevent overweight, formulate a realistic body image, and promote peer acceptance. YOUNG ADULT The respiratory rate of the adolescent is 16 to 20 per minute. Parts of the body grow at various rates, but the respiratory system Growth of the skeletal system is essentially complete by age 25. does not grow proportionately. Therefore, the adolescent may have Muscular efficiency is at its peak between 20 and 30. Energy level inadequate oxygenation and become more fatigued. The lung ca- and control of energy are high. Thereafter, muscular strength de- pacity correlates with the adolescent’s structural form. Boys have a clines with the rate of muscle aging, depending on the specific mus- larger lung capacity than girls because of greater shoulder width cle group, the activity of the person, and the adequacy of his or her and chest size. Boys have greater respiratory volume, greater vital diet. capacity, and a slower respiratory rate. The boy’s lung capacity ma- Regular exercise is helpful in controlling weight and maintaining tures later than the girl’s. Girls’ lungs mature at age 17 or 18. a state of high-level wellness. Muscle tone, strength, and circulation The heart continues to grow during adolescence but more slowly are enhanced by exercise. Problems arise especially when sedentary than the rest of the body, contributing to the common problems of lifestyles decrease the amount of exercise available with daily activ- inadequate oxygenation and fatigue. The heart continues to enlarge ities. Caloric intake and exercise should be balanced. until age 17 or 18. Systolic pulse pressure increases, and the tem- Adequate sleep is important for good physical and mental health. perature is the same as in an adult. The pulse ranges from 50 to 68 Lack of sleep results in progressive sluggishness of both physical beats per minute; respiration ranges from 18 to 20 per minute; and and cognitive functions. This age group gets the majority of its ac- blood pressure is 100 to 120/50 to 70 mm Hg. Adolescent girls have tivity from work and leisure activities. The young adult should slightly higher pulse rates and basal body temperature and lower learn to balance his or her work with leisure-time activities. Getting systolic pressures than boys. Hypertension incidence increases. Es- started in a career can be very stressful and can lead to burnout if sential hypertension incidence is approximately equal between an appropriate balance is not found. Physical fitness reflects ability races for this age group. to work for a sustained period with vigor and pleasure, without un- Athletes have slower pulse rates than peers. Heart sounds are due fatigue, and with energy left over for enjoying hobbies and heard readily at the fifth left intercostal space. Functional murmurs recreational activities and for meeting emergencies.6 should be outgrown by this time. Chest pain may arise from mus- Basic to fitness are regular physical exercise, proper nutrition, ad- culoskeletal changes, but cardiovascular pain should always be in- equate rest and relaxation, conscientious health practices, and good vestigated. Cardiovascular problems are the fifth leading cause of medical and dental care. Regular physical fitness is a natural tran- death in adolescents. quilizer releasing the body’s own endorphins, which reduce anxi- More rest and sleep are needed now than earlier. The teenager is ety and muscular tension. expending large amounts of energy and functioning with an inad- The respiratory system of the young adult has completely ma- equate oxygen supply; both these factors contribute to fatigue and tured. Oxygen demand is based on exercise and activity now but cause the need for additional rest. Parents may need to set limits. gradually decreases between age 20 and 40. The body’s ability to Rest does not necessarily mean sleep and can also include quiet use oxygen efficiently is dependent on the cardiovascular system activities.6 and the needs of the skeletal muscles. Because of the very rapid growth during this period, the adoles- The respiratory system and cardiovascular system change gradu- cent may not have sufficient energy left for strenuous activities. He ally with age, but the rate of change is highly dependent on the in- or she tires easily and may frequently complain of needing to sit dividual’s diet and exercise pattern. Generally, contraction of the down. Gradually the adolescent is able to increase both speed and myocardium decreases. The maximum cardiac output is reached be- stamina during exercise. An increase in muscular and skeletal tween the age of 20 and 30. The arteries become less elastic. The max- strength, as well as the increased ability of the lungs and heart to imum breathing capacity decreases between ages 20 and 40. Cardiac provide adequate oxygen to the tissue, facilitates maintenance of and respiratory function can be improved with regular exercise. Hy- hemodynamics and rate of recovery after exercise. The body pertension (blood pressure 140/90 mm Hg or higher) and mitral Copyright © 2002 F.A. Davis Company 230 ACTIVITY-EXERCISE PATTERN valve prolapse syndrome are the most common cardiovascular med- challenge to older adults attempting to maintain balance, prevent ical diagnoses of the young adult. falls, and have a smooth gait.12 Vestibular changes can impede spatial orientation. The vestibular and nervous system changes in ADULT conjunction with a slowed reaction time, increased postural sway, decreased stride, decreased toe-floor clearance, decreased arm Basal metabolism rate gradually decreases. Although there is a gen- swing, and knee and hip rotation all may impact the mobility level eral and gradual decline in quickness and level of activity, people of older adults.13 who were most active among their age group during adolescence Aging changes to the respiratory system may include a decrease and young adulthood tend to be the most active during middle and in lung elasticity, chest wall stiffness, diminished cough reflex, old age. In women, there is frequently a menopausal rise in energy increased physiologic dead space secondary to air trapping, and and activity.8 Judicious exercise balanced with rest and sleep mod- nonuniform alveolar ventilation.14 Alveolar enlargement and ify and retard the aging process. Exercise stimulates circulation to thinning of alveolar walls mean less alveolar surface is available for all parts of the body, thereby improving body functions. Exercise gas exchange.15 The older adult may experience decreases in PaO2 can also be an outlet for emotional tension. If the person is begin- and increases in PaCO2 because of aging changes in the respiratory ning exercises after being sedentary, certain precautions should be system. taken, such as gradually increasing exercise to a moderate level, ex- Cardiovascular diseases remain the primary cause of death in ercising consistently, and avoiding overexertion. Research indicates the older population.16 With aging, the cardiovascular system un- that cardiovascular risk factors can be reduced in women by low- dergoes changes in structure and function. Left ventricular, aortic intensity walking.9 valve, and mitral valve thickening have an impact on cardiac con- The adult is beginning to have a decrease in bone mass and a loss tractility and systolic blood flow. Increased arterial thickness and of skeletal height. Muscle strength and mass are directly related to arterial stiffening may lead to a decrease in the effectiveness of active muscle use. The adult needs to maintain the patterns of ac- baroreceptors. Diminished baroreceptor response has an effect tivity and exercise of young adulthood and not become sedentary. on the body’s ability to control blood pressure with postural Otherwise, muscles lose mass structure and strength more rapidly. changes. Pacemaker cells in the sinoatrial node decrease with ag- Temperature for the adult ranges from 97 to 99.6F; pulse ranges ing. Calcification may occur along the conduction system of the from 50 to 100 beats per minute; respiration ranges from 16 to 20 heart. Myocardial irritability leads to the potential for increased per minute; and blood pressure is 120/80 mm Hg  15. Cardiac cardiac arrhythmias.15 The ability of the cardiovascular system to output gradually decreases, and the decreasing elasticity of the respond to increased demands becomes reduced, and the older blood vessels causes more susceptibility to hypertension and car- adult experiences a decrease in physiologic reserves.15 These diovascular diseases. Women become as prone to coronary disease changes can have serious consequences when the older adult ex- after menopause as men, so estrogen appears to be a protective periences physical or psychological stress. It becomes increasingly agent. The BMR generally decreases. Essential and secondary hy- difficult for the older adult to have rapid and efficient blood pres- pertension and angina occur more frequently in this age group. sure and heart rate changes. Vital sign ranges for older adults are The lung tissue becomes thicker and less elastic with age. The similar to those for middle-age adults. There may be a slight in- lungs cannot expand as they once did, and breathing capacity is re- crease in respiratory rate,12 and blood pressure increases, espe- duced. The respiratory rate may increase to compensate for the re- cially systolic changes, are often present. Healthy older men, from duced breathing capacity. age 50 onward, may experience a 5 to 8 mm Hg increase in sys- The normal adult should be able to perform activities of daily liv- tolic blood pressure per decade. Healthy older women, from age ing without assistance. The needs for close relationships and inti- 40 onward, may have similar systolic changes.17 Diastolic changes macy of adulthood can be initiated by leisure activities with identi- are usually minimal. fied partners or a small group of close friends (e.g., hiking, tennis, With the potential age-related changes just described, some golf, or attending concerts or theatres, etc.). The middle-age adult is older adults may experience changes in function. Many of the often interested in the personal satisfaction of diversional activities. changes combined can lead to problems with energy available to The adult will most likely be responsible for home maintenance cells, organs, and systems to accomplish desired activities. Health as well as outside employment. Role strain or overtaxation of the promotion efforts should focus on activity and exercise and their adult is possible. Illness or injury to the adults in the household will impact on the older adult’s sense of well-being. Research in the significantly affect the ability of the family unit to maintain the 1990s has shown the benefits to older adults when weight training home. and exercise are a part of their lifestyle.18 Older clients may need prompting and reminders to pace their activities to compensate for OLDER ADULT aging changes. The increase in leisure time associated with retire- ment and a lessening of occupational and child-rearing responsi- Older adults face a gradual decline in function through the years. bilities create the opportunity for exploring other activity options. Age-related changes in the cardiovascular, respiratory, and muscu- The older adult has the developmental challenge of finding loskeletal systems vary from person to person. Studies attempting meaning in the course of the life they have lived and feeling com- to describe age-related system changes have faced problems in de- fort with the results of their actions and choices.19 Strategies to sup- termining what changes may be age-related versus disease- port this task may take on the form of life review with the older induced.11 client, promoting reminiscing, and other opportunities for the Changes in the older musculoskeletal system typically include older adult to acknowledge

and experience self-worth.20 decreases in bone volume and strength, decreases in skeletal mus- Because of the diversity of our older population, individualized cle quality and mass, and reductions in muscle contractility.11 Ten- assessment is a high priority. The age-related changes cited in this don and ligament strength decrease with aging, and collagen stiff- section are not universal and inevitable for all older adults. Health ness and cross-linking occur. The tendon and ligament changes can care providers need to be wary of stereotyping clients based on age. result in joint range-of-motion losses of from 20 to 25 percent.11 There are many independent older adults in our society, and the Changes in older adults vestibular and nervous systems present a number is increasing. Copyright © 2002 F.A. Davis Company ACTIVITY INTOLERANCE, RISK FOR AND ACTUAL 231 3. History of previous intolerance APPLICABLE NURSING DIAGNOSES 4. Deconditioned status B. Activity Intolerance 1. Verbal report of fatigue or weakness 2. Abnormal heart rate or blood pressure response to activity Activity Intolerance, Risk for and Actual 3. Electrocardiographic changes reflecting arrhythmias or is- chemia DEFINITIONS21 4. Exertional discomfort or dyspnea Risk for Activity Intolerance A state in which an individual is at risk of experiencing insufficient physiologic or psychological en- RELATED FACTORS21 ergy to endure or complete required or desired daily activities. A. Risk for Activity Intolerance Activity Intolerance A state in which an individual has insuffi- The risk factors also serve as the related factors for this diagnosis. cient physiologic or psychological energy to endure or complete re- B. Activity Intolerance quired or desired daily activities. 1. Bedrest or immobility 2. Generalized weakness NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 3. Imbalance between oxygen supply and demand CLASS 4—CARDIOVASCULAR/PULMONARY 4. Sedentary lifestyle RESPONSE RELATED CLINICAL CONCERNS NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; CLASS A—ACTIVITY AND EXERCISE MANAGEMENT 1. Anemias 2. Congestive heart failure NOC: DOMAIN I—FUNCTIONAL HEALTH; 3. Valvular heart disease CLASS A—ENERGY MAINTENANCE 4. Cardiac arrhythmia 5. Chronic obstructive pulmonary disease (COPD) DEFINING CHARACTERISTICS21 6. Metabolic disorder 7. Musculoskeletal disorders A. Risk for Activity Intolerance (Risk Factors) 1. Inexperience with the activity 2. Presence of circulatory or respiratory problems HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Physical Mobility This diagnosis implies increased energy and oxygen demands made. A that an individual would be able to move person may have a self-care deficit as a result of independently if something were not limiting the activity intolerance. motion. Activity Intolerance implies that the Ineffective Individual Coping Persons with the individual is freely able to move but cannot endure diagnosis of Ineffective Individual Coping may be or adapt to the increased energy or oxygen unable to participate in their usual roles or in their demands made by the movement or activity. usual self-care because they feel they lack control Self-Care Deficit Self-Care Deficit indicates that or the motivation to do so. Activity Intolerance, on the patient has some dependence on another the other hand, implies that the person is willing person. Activity Intolerance implies that the patient and able to participate in activities but is unable to is independent but is unable to perform activities endure or adapt to the increased energy or oxygen because the body is unable to adapt to the demands made by the movement or activity. EXPECTED OUTCOME TARGET DATES Will participate in increased self-care activities by [date]. (Specify Appropriate target dates will have to be individualized according to which self-care activities, that is, bathing, feeding, dressing, or am- the degree of activity intolerance. An appropriate range would be 3 bulation, and the frequency, duration, or intensity of the activity.) to 5 days. EXAMPLE Will increase walking by at least 1 block each week for 8 weeks. Copyright © 2002 F.A. Davis Company 232 ACTIVITY-EXERCISE PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor current potential for desired activities, including: Provides baseline for planning activities and increase in activities. � Physical limitations related to illness or surgery � Factors that relate to desired activities � Realistic expectations for actualizing potential for desired activities � Objective criteria by which specific progress may be measured, e.g., distance, time, and observable signs or symptoms such as apical pulse, respiration � Previous level of activities the patient enjoyed • Assist the patient with self-care activities as needed. Let the Allows the patient to have some control and choice in plan; helps patient determine how much assistance is needed. the patient to gradually decrease the amount of activity intolerance. • Monitor and record blood pressure, pulse, and respiration Vital signs increase with activity and should return to baseline before and after activities. within 5–7 min after activity. Maximal effort should be greater than or equal to 60–80 percent over the baseline. • Encourage progressive activity and increased self-care as Gradually increases tolerance for activities. tolerated. Schedule moderate increase in activities on a daily basis, e.g., will walk 10 ft farther each day. • Collaborate with physician regarding oxygen therapy. Promotes teamwork. Oxygen may be needed for shortness of breath associated with increased activity. • Collaborate with a physical therapist in establishing an Provides most appropriate activities for the patient. appropriate exercise plan. • Collaborate with an occupational therapist for appropriate diversional activity schedule. • Teach the client appropriate exercise methods to prevent injury, Basic safety measures to avoid complicating condition. e.g., no straight-leg sit-ups; proper muscle stretching and warm-up before aerobic exercise; reaching target heart rate; stopping exercise if experiencing pain, excessive fatigue, nausea, or breathlessness. • Encourage rest as needed between activities. Assist the patient Planned rest assists in maintaining and increasing activity tolerance. in planning a balanced rest-activity program. • Provide for a quiet, nonstimulating environment. Limit number Determine various methods to motivate behavior. of visitors and length of their stay. Teach relaxation and alternate pain relief measures. Assess internal and external motivators for activities, and record here. • Encourage adequate dietary input by ascertaining the patient’s Provides adequate nutrition to meet metabolic demands. food preferences and consulting with dietitian. • Assist the patient in weight reduction as required. Decreased weight requires less energy and oxygen use. • Teach the patient relationship between nutrition and exercise Assists the patient to learn alternate methods to conserve energy in tolerance, and assist in developing a diet that is appropriate for activities of daily living. nutritional and metabolic needs (see Chapter 3 for further information). • Assist the patient in acquiring equipment to perform desired exercise (list needed equipment here; this could include proper shoes, eyeglasses, or weights). • Instruct the patient in energy-saving techniques of daily care, e.g., preparing meals sitting on a high stool rather than standing. • Provide opportunities of 15–30 min per shift for allowing the patient and family to verbalize concerns regarding activity. • Introduce necessary teaching according to the readiness of the Assists in reducing anxiety, promotes long-range planning, and patient and family with appropriate modifications to best meet provides a teaching opportunity. Ensures that teaching meets the the patient’s needs. patient’s level of understanding and need. • Provide the patient and family opportunities to contribute to The more the patient and family participate in planning, the more plans for activity as appropriate. Allow for individual preference likely they are to implement the desired regimen. and suggestions on an ongoing basis. • Provide opportunities for success in meeting expected goals by Achieving success motivates the patient to continue the activity. using subgoals or increments that lead to desired activity. Copyright © 2002 F.A. Davis Company ACTIVITY INTOLERANCE, RISK FOR AND ACTUAL 233 Child Health ACTIONS/INTERVENTIONS RATIONALES • Provide learning modules and practice sessions with materials Developmentally appropriate materials enhance learning and suitable for the child’s age and developmental capacity, e.g., maintain the child’s attention. dolls, videos, or pictures. • Provide for continuity in care by assigning same nurses for care Continuity of caregivers fosters trust in the nurse-patient during critical times for teaching and implementation. relationship, which enhances learning. • Modify expected behavior to incorporate appropriate Valuing of the patient’s developmental needs fosters self-esteem and developmental needs, e.g., allow for shared cards, messages, or serves as a reward for efforts. visitors to lobby if possible for adolescent patients. • Reinforce adherence to regimen with stickers or other Extrinsic rewards may help symbolize concrete progress and assists appropriate measures to document progress. in reinforcing appropriate behaviors for achieving goals. Women’s Health ACTIONS/INTERVENTIONS RATIONALES PREMATURE RUPTURE OF MEMBRANES22,23 NOTE: Approach to treatment is controversial and depends on practice in your particular area. • Carefully monitor fetal heart rate to detect cord compression and/or cord prolapse. • Carefully monitor for signs and symptoms of amnionitis. � Check maternal temperature every 4 h. � Evaluate for uterine tenderness at least twice a day. � Check daily leukocyte counts. � Avoid vaginal examinations. • Keep the patient and partner informed, and encourage their participation in management decisions. • Explain and provide answers to questions regarding: Assists in reducing fears of expectant parents and increasing the � Possible preterm delivery likelihood of a good outcome for the pregnancy. � Fetal lung maturity and possible use of corticosteroids to accelerate fetal lung maturity • Provide comfort measures to decrease intolerance of bedrest: � Back or body massage � Diversional activities, such as television, reading, or handicrafts � Bedside commode (if acceptable to treatment plan) PRETERM LABOR24–26 NOTE: Although there is disagreement on the definition, the most widely used definition of preterm labor is 6 to 8 contractions per hour or 4 contractions in 20 min associated with cervical change.24 • Thoroughly explain to the patient and partner the process of preterm labor. • Discuss options of activity allowed. Provides the parents with information, increases motivation to continue with reduced activity, and allows informed choices. NOTE: This varies, and there is controversy in the literature on the value of bedrest for preterm labor; therefore, look at practice in your area. • Discuss various treatment possibilities: � Prolonged bedrest or at least a marked reduction in activity � Intravenous volume expansion (IV therapy) � Tocolytic therapy (IV, oral, or pump) � Use of magnesium sulfate � Use of prostaglandin synthesis inhibitors such as indomethacin � Use of calcium channel blockers (continued) Copyright © 2002 F.A. Davis Company 234 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Carefully monitor those patients receiving tocolytic therapy for: � Pulmonary edema � Hypokalemia � Hyperglycemia � Shortness of breath � Chest pain � Cardiac dysrhythmia � Electrocardiographic “ischemia” changes � Hypotension • Carefully monitor uterine contractions (strength, quality, frequency, and duration). • Monitor fetal heart rate in association with contractions. • Provide diversional activities for those patients on bedrest. • Refer for home monitoring and evaluation if appropriate: Increases compliance, decreases cost, and decreases maternal stress � Assess the patient’s ability to identify contractions. when she can achieve treatment at home instead of in an acute care � Evaluate the patient’s support system at home. setting. � Assess the patient’s access to health care provider. PREGNANCY-INDUCED HYPERTENSION (PIH)27,28 • Explain the various screening procedures for PIH to the patient and partner: � Blood pressure measurement � Urine checked for protein � Assessment of total and interval weight gain � Signs and symptoms of sudden edema of hands and face, sudden 5-lb weight gain in 24–48 h, epigastric pain, or spots before eyes or blurred vision • Discuss treatment plan with the patient and partner: � Bedrest on either side (right or left) � Magnesium sulfate therapy � Reduction in noise, visual stimuli, and stress � Careful monitoring of fetal heart rate � Possible sonogram to determine interuterine growth rate (IUGR) � Good nutrition with a maximum recommended daily allowance (RDA) sodium intake of 110–3300 mg/day • Assess the patient’s support system to determine whether the patient can be treated at home.29,30 • Assist the family in planning for needed caretaking and housekeeping activities if the patient is at home.29,30 • Consult with perinatalogist and visiting nurse to implement collaborative care plan. • Ensure that the family knows procedure for obtaining emergency service. UNCOMPLICATED PREGNANCY NOTE: Even though there are often no complications in pregnancy, it is not unusual, particularly during the last 4 to 6 weeks, to have activities restricted because of edema, bouts with false labor, and fatigue. This fatigue continues after the birth, when the mother and father become responsible for the care of a newborn

infant 24 h a day. • Discuss with the expectant parents methods of conserving energy while continuing their daily activities during the last weeks of pregnancy. • Assist the expectant mother in developing a plan whereby she Provides opportunity to rest throughout the day and therefore the can take frequent (2 in the morning, 2 in the afternoon), short ability to maintain as many routine activities as possible. Increases breaks during the work day to: oxygen flow to the uterus and the fetus, thereby reducing the � Retain energy and reduce fatigue. possibility of preterm labor and severe fatigue. � Reduce the incident of false labor. � Increase circulation and thus reduce dependent lower limb edema and increase oxygen to the placenta and fetus. (continued) Copyright © 2002 F.A. Davis Company ACTIVITY INTOLERANCE, RISK FOR AND ACTUAL 235 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the expectant parents to plan for the possibility of reducing the number of hours the woman works during the week. Look at work schedule and talk with employer about: � Working every other day � Working only half-day each day � Working 3 days in the middle of the week, i.e., Tuesday, Wednesday, and Thursday, thus, having a 4-day weekend to rest � Job sharing AFTER DELIVERY • Instruct the patient in energy-saving activities of daily care: A common problem with a new baby is overwhelming fatigue on � Take care of self and baby only. the part of the mother. These measures will assist in decreasing the � Let the partner and others take care of housework and other fatigue. children. � Let the partner and others take care of the baby for a prearranged time during the day so the mother can spend quality time with the other children. � Learn to sleep when the baby sleeps. � Turn off telephone or turn on answering machine. � Have specific times set for visiting of friends or relatives. � If breastfeeding, partner can change the infant and bring the infant to the mother at night. (The mother does not always have to get up and go to the infant.) • Consider taking the baby to bed with the parent. Newest research shows that taking the baby to bed with the mother and father at night for the first few weeks24: � Allows the mother, father, and infant to get more rest. � Provides more time for the baby to nurse, and baby begins to sleep longer more quickly. � Possibly reduces the incidence of sudden infant death syndrome (SIDS) because the baby mimics the breathing patterns of the mother and father. � Promotes positive learning and acquaintance activities for the new parents. Allows the infant to feel more secure, and therefore increases infant-to-parent attachment. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client his or her perceptions of activity Provides an understanding of the client’s worldview so that appropriate to his or her current capabilities. care can be individualized and interventions developed that are acceptable to both the nurse and the client.31 • If the client estimates a routine that far exceeds current capabilities (as with eating disorder clients or clients experiencing elated mood): � Establish appropriate limits on exercise. (The limits and Negative reinforcement eliminates or decreases behavior.32 consequences for not maintaining limits established should Because of the high energy level, elated clients need some be listed here. If the excessive exercise pattern is related to an large motor activity that will discharge energy but does not elated mood, set limits in a manner that allows the client present a risk for physical harm.33 some activity while not greatly exceeding metabolic needs until psychological status is improved.) � Begin the client slowly, e.g., with stretching exercise for Goals need to be achievable to promote the sense of 15 min twice a day. accomplishment and positive self feelings, which will in turn increase motivation.31 � As physical condition improves, gradually increase exercise A regimen that provides positive cardiovascular fitness without risk to 30 min of aerobic exercise once per day. of overexertion.33 � Discuss with the client appropriate levels of exercise Overexertion can decrease benefits of exercise by increasing risk for considering his or her age and metabolic pattern. injury.34 � Discuss with client the hazards of overexercise. (continued) Copyright © 2002 F.A. Davis Company 236 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Establish a reward system for clients who maintain the Positive reinforcement encourages appropriate behavior.32 established exercise schedule (the schedule for the client should be listed here with those reinforcers that are to be used). � Stay with the client while he or she is engaged in appropriate Interaction with the nurse can provide positive reinforcement.32 exercise. � Develop a schedule for the client to be involved in an Promotes accurate perception of body size, nutrition, and exercise occupational therapy program to assist the client in needs. identifying alternative forms of activity other than aerobic exercise. � Limit number of walks off the unit to accommodate client’s weight, level of exercise on the unit, and physiology (the frequency and length of the walk should be listed here). • For further information related to eating disorder clients, see Imbalanced Nutrition, Less Than Body Requirements (Chap. 3). • If the client’s expectations are much less than current capabilities Goals need to be achievable to promote sense of accomplishment (as with a depressed or poorly motivated client), implement the and positive self feelings, which will in turn increase motivation.31 following actions: � Establish very limited goals that the client can accomplish, e.g., a 5-min walk in a hallway once a day or walking in the client’s room for 5 min. The goal established should be listed here. � Establish a reward system for achievement of goals (the Positive reinforcement encourages appropriate behavior.32 reward program should be listed here with a list of items the client finds rewarding). � Develop a schedule for the client to be involved in an Provides the client with opportunity to improve self-help skills occupational therapy program (note schedule here). while engaged in a variety of activities. � Establish limits on the amount of time the client can spend in Exercise raises levels of endorphins in the brain, which has a bed or in his or her room during waking hours (establish positive effect on depression and general feeling of well-being.33,35 limits the client can achieve, and note limits here). � Stay with the client during exercise periods and time out of Interaction with the nurse can provide positive reinforcement.32 the room until the client is performing these tasks without prompting. � Provide the client with firm support for initiating the activity. Attention from the nurse can provide positive reinforcement and increase the client’s motivation to accomplish goal. � Place a record of goal achievement where the client can see it, Provides concrete evidence of goal attainment and motivation to and mark each step toward the goal with a reward marker. continue these activities that will promote well-being. � Provide positive verbal reinforcement for goal achievement and progress. • For further information about clients with depressed mood, refer to Ineffective Individual Coping (Chap. 11). • Monitor effects current medications may have on activity Psychotropic medications may cause postural hypotension, and the tolerance, and teach the client necessary adjustments. client should be instructed to change position slowly. • Schedule time to discuss plans and special concerns with the Recognizes the reciprocity between the client’s illness and the family client and the client’s support system. This could include context.36 teaching and answering questions. Schedule daily during initial days of hospitalization and one longer time just before discharge. Note schedule times and person responsible for this. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Determine, with the assistance of the patient, particular time Maximizes potential to successfully participate in or complete care periods of highest energy, and plan care accordingly. requirements. • Teach the patient to monitor pulse before, during, and after Promotes self-monitoring and provides means of determining activity. progress across care settings. • Refer the patient to occupational therapy and physical therapy Collaboration ensures a plan that will result in activity for for determination of a progressive activity program. maximum effect. • Establish goals that can be met in a short time frame (daily or Provides motivation to continue program.37 weekly). (continued) Copyright © 2002 F.A. Davis Company ACTIVITY INTOLERANCE, RISK FOR AND ACTUAL 237 (continued) ACTIONS/INTERVENTIONS RATIONALES • Use positive feedback for incremental successes. Reinforces the older adult’s potential to have efforts produce positive outcomes. Enhances sense of self-efficacy.38 • Monitor for signs of potential complications related to Older adults are highly susceptible to the negative physiologic and decreased activity level, such as problems with skin integrity, psychological consequences of immobility.39 elimination complications, and respiratory problems. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of causes, Provides baseline for prevention and/or early intervention. signs, and symptoms of risk for or actual activity intolerance: � Prolonged bedrest � Circulatory or respiratory problems � New activity � Fatigue � Dyspnea � Pain � Vital signs (before and after activity) � Malnutrition � Previous inactivity � Weakness � Confusion • Assist the client and family in identifying lifestyle changes that Lifestyle changes require sufficient support to achieve. may be required: � Progressive exercise to increase endurance � Range of motion (ROM) and flexibility exercises � Treatments for underlying conditions (cardiac, respiratory, musculoskeletal, circulatory, etc.) � Motivation � Assistive devices as required (walkers, canes, crutches, wheelchairs, exercise equipment, etc.) � Adequate nutrition � Adequate fluids � Stress management � Pain relief � Prevention of hazards of immobility � Changes in occupations or family or social roles � Changes in living conditions � Economic concerns • Teach the client and family purposes and side effects of Changes locus of control to the client and family, and supports medications and proper administration techniques. self-care. • Assist the client and family to set criteria to help them determine Provides additional support for the client. when calling a physician or other intervention is required. • Consult with or refer to appropriate assistive resources as indicated. Copyright © 2002 F.A. Davis Company 238 ACTIVITY-EXERCISE PATTERN Activity Intolerance, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient demonstrated an increase in self-care activities; e.g., can now bathe without fatigue and discomfort? Yes No Record data, e.g., can bathe and feed self Reassess using initial assessment factors. without discomfort; BP and pulse now remain within normal limits following these activities. Record RESOLVED. (May wish to use CONTINUE until entire medical diagnosis is resolved.) Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has problems with fatigue and weakness after Did evaluation show another any activity; pulse increases to problem had arisen? Yes 110%; BP rises to 180/100. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company AIRWAY CLEARANCE, INEFFECTIVE 239 Airway Clearance, Ineffective RELATED FACTORS21 DEFINITION 1. Environmental a. Smoking Inability to clear secretions or obstructions from the respiratory b. Smoke inhalation tract to maintain a clear airway.21 c. Second-hand smoke 2. Obstructed airway NANDA TAXONOMY: DOMAIN 11—SAFETY/ a. Airway spasm PROTECTION; CLASS 2—PHYSICAL INJURY b. Retained secretions c. Excessive mucus NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; d. Presence of artificial airway CLASS K—RESPIRATORY MANAGEMENT e. Foreign body in airway NOC: DOMAIN II—PHYSIOLOGIC HEALTH; f. Secretions in the bronchi CLASS E—CARDIOPULMONARY g. Exudate in the alveoli 3. Physiologic a. Neuromuscular dysfunction DEFINING CHARACTERISTICS21 b. Hyperplasia of the bronchial walls c. Chronic obstructive pulmonary disease 1. Dyspnea d. Infection 2. Diminished breath sounds e. Asthma 3. Orthopnea f. Allergic airways 4. Adventitious breath sounds (rales, crackles, rhonchi, and wheezes) 5. Cough, ineffective or absent RELATED CLINICAL CONCERNS 6. Sputum 1. Adult respiratory distress syndrome (ARDS) 7. Cyanosis 2. Pneumonia 8. Difficulty vocalizing 3. Cancer of the lung 9. Wide-eyed 4. Chronic obstructive pulmonary disease (COPD) 10. Changes in respiratory rate and rhythm 5. Congestive heart failure 11. Restlessness 6. Cystic fibrosis 7. Inhalation injuries 8. Neuromuscular diseases HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Breathing Pattern This diagnosis air passages, but

a problem arises at the cellular implies an alteration in the rate, rhythm, depth, or level. type of respiration, such as hyperventilation or Deficient Fluid Volume When fluid volume is hypoventilation. These patterns are not effective in insufficient to assist in liquefying thick, tenacious supplying oxygen to the cells of the body or in respiratory tract secretions, Deficient Fluid Volume removing the products of respiration. However, air then becomes the primary diagnosis. In this is able to move freely through the air passages. In instance, the patient would be unable to effectively Ineffective Airway Clearance, the air passages are expectorate the secretions no matter how hard he obstructed in some way. or she tried, and Ineffective Airway Clearance Impaired Gas Exchange This diagnosis means that would result. air has been inhaled through the air passages but Pain If pain is sufficient to prevent the patient from that oxygen and carbon dioxide are not coughing to clear the airway, then Ineffective appropriately exchanged at the alveolar-capillary Airway Clearance will result secondary to the pain. level. Air has been able to pass through clear EXPECTED OUTCOME ADDITIONAL INFORMATION Will have an open, clear airway by [date]. The various ways of measuring lung volume and capacity are sum- marized and defined in Table 5–1. TARGET DATES Ineffective airway clearance is life-threatening; therefore, progress toward meeting the expected outcome should be evaluated at least on a daily basis. Copyright © 2002 F.A. Davis Company 240 ACTIVITY-EXERCISE PATTERN TABLE 5–1. LUNG CAPACITIES AND VOLUMES AVERAGE VALUE, ADULT MALE RESTING MEASUREMENT (ML) DEFINITION Tidal volume (TV) 500 Amount of air inhaled or exhaled with each breath Inspiratory reserve volume (IRV) 3100 Amount of air that can be forcefully inhaled after a normal tidal volume inhalation Expiratory reserve volume (ERV) 1200 Amount of air that can be forcefully exhaled after a normal tidal volume exhalation Residual volume (RV) 1200 Amount of air left in the lungs after a forced exhalation Total lung capacity (TLC) 6000 Maximum amount of air that can be contained in the lungs after a maximum inspiration: TLC  TV
IRV
ERV
RV Vital capacity (VC) 4800 Maximum amount of air that can be expired after a maximum inspiration: VC  TV
IRV
ERV Should be 80% of TLC Inspiratory capacity (IC) 3600 Maximum amount of air that can be inspired after a normal expiration: IC  TV
IRV Functional residual capacity (FRC) 2400 Volume of air remaining in the lungs after a normal tidal volume expiration: FRC  ERV
RV NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Maintain appropriate emergency equipment as dictated by Basic safety precautions. situation (e.g., tracheostomy sterile setup or suctioning apparatus). • Monitor respiratory rate, depth, and breath sounds at least Basic indicators of airway patency. every 4 h. • Collaborate with physician regarding frequency of blood gas Assists in determining changes in ventilatory status, and promotes measurements. teamwork. • Give mucolytic agents via nebulizer or intermittent Helps thin and loosen secretion; expands airways. positive-pressure breathing (IPPB) treatments or continuous positive airway pressure (CPAP) as ordered. • Monitor effects and side effects of medications used to open the Assists in determining whether airflow or lung volume is improved patient’s airways (bronchodilators, corticosteroids), e.g., for an via medication. aminophylline IV drip, ensure appropriate dilution, note incompatibility factor, monitor for nausea, increased heart rate, irritability, etc. Document effect within 30 min after administration. • Maintain adequate fluid intake to liquefy secretions. Encourage Assists in liquefaction of secretions, and provides moisture to the intake up to 3000 mL per day (unless contraindicated). Measure pulmonary mucosa. output each 8 h. • Have the patient’s favorite fluids available: � Remind the patient to drink fluids at least every hour while awake. � Provide warm or hot drinks instead of cold fluids. • Assist the patient in coughing, huffing, and breathing efforts to Deep breathing and diaphragmatic breathing allow for greater lung make them more productive: expansion and ventilation as well as a more effective cough. � Sit in upright position. � Take a deep, slow breath while expanding abdomen, allowing diaphragm to expand. � Hold breath for 3–5 s. (continued) Copyright © 2002 F.A. Davis Company AIRWAY CLEARANCE, INEFFECTIVE 241 (continued) ACTIONS/INTERVENTIONS RATIONALES � Exhale the breath slowly through the mouth while abdomen moves inward. � Pause briefly before next breath in. � Cough with the second breath inward; cough forcefully from chest (these should be two short, forceful coughs). � Place hands on upper abdomen and exert inward, upward pressure during cough (splint incision or painful areas during procedure). � Maintain adequate humidity in environment (80 percent). • Observe the patient practicing proper breathing techniques 30 min twice a day (note time of practice sessions here). • Assist with cupping and clapping activities every 4 h while Cupping and clapping loosen secretions and assist expectoration. awake at [times]. Teach the family these procedures. Teaching the family allows them to participate in care under supervision and promotes continuation of the procedure after discharge. • Assist the patient with clearing secretions from mouth or nose by: Removes tenacious secretions from airways. � Providing tissues � Using gentle suctioning if necessary • Assist the patient with oral hygiene at least every 4 h while Oral hygiene clears away dried secretions and freshens the mouth. awake at [times]: Oil-based products may obstruct breathing passages. � Lubricate lips with a moisturizing agent. � Do not allow the use of oil-based products around the nose. • Discuss with the patient importance of maintaining proper Facilitates expansion of the diaphragm; decreases probability of position to include: aspiration. � Side-lying position while in bed � Sitting or standing position with shoulders back and with back as straight as possible to facilitate expansion of the diaphragm • Remind the patient of proper positioning as required. • Promote rest and relaxation by scheduling treatments and Avoids overexertion and worsening of condition. activities with appropriate rest periods. • Instruct the patient to avoid irritating substances, large crowds, Prevents infection or airway spasms. and persons with upper respiratory infections. • Discuss with the patient factors contributing to ineffective Smoking increases production of mucus and paralyzes or causes airway clearance, e.g., cigarettes or alcohol. Refer, prior to loss of cilia. discharge, to a stop-smoking program at a community agency such as: � American Cancer Society � American Heart Association � American Lung Association • Refer the patient for appropriate consultations as needed, e.g., Promotes cost-effective use of resources, and promotes follow-up respiratory therapy or physical therapy. care. • Provide for appropriate follow-up by scheduling appointments before dismissal. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor patient factors that relate to ineffective airway clearance, Provides an individualized data baseline that facilitates including: individualized care planning. � Feeding tolerance or intolerance � Allergens � Emotional aspects � Stressors of recent or past activities � Congenital anomalies � Parental anxieties � Infant or child temperament � Abdominal distention � Related vital signs, especially heart rate (continued) Copyright © 2002 F.A. Davis Company 242 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Diaphragmatic excursion � Retraction in respiratory effort � Choking, coughing � Flaring of nares � Appropriate functioning of respiratory equipment • Provide appropriate attention to suctioning and related Ensures basic maintenance of airway and respiratory function. respiratory maintenance: Gives priority attention to the child’s status and developmental level. � Appropriate size for catheter as needed � Appropriate administration of humidified oxygen as ordered by physician � Appropriate follow-up of blood gases � Documentation of oxygen administration, characteristics of secretions obtained by suctioning, and vital signs during suctioning, reporting apical pulse 70 or 149 beats per min for an infant or 90 or 120 beats per min for a young child • Encourage the parent’s input in planning care for the patient, Promotes family empowerment, and thus promotes the likelihood with attention to individual preferences when possible. of more effective management of therapeutic regimen after discharge. • Provide health teaching as needed based on assessment and the Allows timely home care planning, family time to ask questions, child’s situation. practicing of techniques, etc. before discharge. Assists in reducing anxiety, and promotes continuance of therapeutic regimen. • Plan for appropriate follow-up with health team members. Provides for long-term support and effective management of therapeutic regimen. • Reduce apprehension by providing comforting behavior and Sensitivity to individual feelings and needs builds trust in the meeting developmental needs of the patient and family. nurse-patient-family relationship. • Allow for diversional activities to approximate tolerance of the . Realistic opportunities for diversion will be chosen based on what child the patient is capable of doing and what will leave the patient feeling refreshed and renewed for having participated. • Encourage the family members to assist in care of the patient, Return-demonstration provides feedback to evaluate skills and with use of return-demonstration opportunities for teaching serves to provide reinforcement in a supportive environment. required skills. Involvement of the parents also satisfies emotional needs of both the parent and child. • Provide for appropriate safety maintenance, especially with Appropriate safety measures must be taken with the use of oxygen administration (no smoking), and appropriate combustible potentials whose use out of prescribed parameters may precautions for age and developmental level. be toxic. • Allow ample time for parental mastery of skills identified in Greater success in compliance and confidence is afforded by care of the child. providing ample time for skills that require mastery. Women’s Health NOTE: The following nursing actions pertain to the newborn infant in the delivery room immediately following delivery. See Adult Health and Home Health for actions related to the mother. ACTIONS/INTERVENTIONS RATIONALES • Evaluate and record the respiratory status of the newborn infant: Basic measures to clear the newborn’s airway. Deep suctioning � Suction and clear mouth and pharynx with bulb syringe. would stimulate reflexes that could result in aspiration. � Avoid deep suctioning if possible. • Continue to evaluate the infant’s respiratory status, and act if Basic protocol for the infant who has difficulty immediately after necessary to resuscitate. Depending on the infant’s response, the birth. following nursing measures can be taken: � Administer warm, humid oxygen with face mask. � If no improvement, administer oxygen with bag and mask. � If no improvement, be prepared for: (1) Endotracheal intubation (2) Ventilation with positive pressure (3) Cardiac massage (4) Transport to neonatal intensive care unit Copyright © 2002 F.A. Davis Company AIRWAY CLEARANCE, INEFFECTIVE 243 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with physician for possible use of saline gargles or These medications can cause blood dyscrasias that present with the anesthetic lozenge for sore throats (report all sore throats to symptoms of sore throat, fever, malaise, unusual bleeding, and easy physician, especially if the client is receiving antipsychotic bruising. Early intervention is important for patient safety.40 drugs and in the absence of other flu or cold symptoms). • Remind the client to chew food well, and sit with the client Provides safety for the client with alterations of mental status. during mealtime if cognitive functioning indicates a need for close observation. Note any special adaptations here (e.g., soft foods, observation during meals, etc.) Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Encourage coughing and deep-breathing exercises every 2 h on Provides exercise in techniques that assist in clearing the airway. [odd/even] hour. • Provide small, frequent feedings during periods of dyspnea. Conserves energy and promotes ventilation efforts. • Instruct the patient regarding early signs of respiratory Early recognition of signs of infection promotes early intervention infections, e.g., increased amount or thickness of secretions, and avoidance of severe infection. increased cough, or changes in color of sputum produced. • Encourage increased mobility, as tolerated, on a daily basis. Mobility helps increase rate and depth of respiration as well as decreasing pooling of secretions. • Teach the patient to complete prescribed course of antibiotic Because of economic factors, patients commonly stop therapy therapy. before the designated time frame, “saving” the medication for possible future episodes. • Monitor for the use of sedative medications that can decrease These medications can decrease the level of altertness and the level of alertness and respiratory effort. respiratory effort. • Collaborate with physician regarding the use of cough Decreases episodes of persistent, nonproductive coughing. suppressants. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and

family appropriate monitoring of signs and Provides for early recognition and intervention for problem. symptoms of ineffective airway clearance: � Cough (effective or ineffective) � Sputum � Respiratory status (cyanosis, dyspnea, and rate) � Abnormal breath sounds (noisy respirations) � Nasal flaring � Intercostal, substernal retraction � Choking, gagging � Diaphoresis � Restlessness, anxiety � Impaired speech � Collection of mucus in mouth • Assist the client and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Eliminating smoking � Treating fear or anxiety � Treating pain � Performing pulmonary hygiene: (1) Clearing the bronchial tree by controlled coughing (2) Decreasing viscosity of secretions via humidity and fluid balance (3) Postural drainage (continued) Copyright © 2002 F.A. Davis Company 244 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Learning stress management � Ensuring adequate nutritional intake � Learning diaphragmatic breathing � Administering pain relief � Beginning progressive ambulation (avoiding fatigue) � Maintaining position so that danger of aspiration is decreased � Maintaining body position to minimize work of breathing and cleaning airway � Ensuring adequate oral hygiene � Clearing secretions from throat � Suctioning as needed � Keeping area free of dust and potential allergens or irritants � Ensuring adequate hydration (monitor intake and output) • Teach the client and family purposes, side effects, and proper administration techniques of medications. • Assist the client and family to set criteria to help them Locus of control shifts from nurse to the client and family, thus determine when calling a physician or other intervention is promoting self-care. required. • Teach the family basic cardiopulmonary resuscitation (CPR). • Consult with or refer to appropriate assistive resources as Provides additional support for the client and family, and uses indicated. already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company AIRWAY CLEARANCE, INEFFECTIVE 245 Airway Clearance, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Review physical assessment of chest. Does the patient have normal breath sounds? Normal respiratory rate and depth? Absence of dyspnea, etc.? Yes No Record data, e.g., chest sounds clear, Reassess using initial assessment factors. respiratory rate 16, good depth, no signs or symptoms of dyspnea or cyanosis. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., rales present in left lower lobe; respiratory rate Did evaluation show another of 26 and shallow. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 246 ACTIVITY-EXERCISE PATTERN Autonomic Dysreflexia, Risk for and Actual 5. Musculoskeletal-integumentary stimuli a. Cutaneous stimulation (e.g., pressure ulcer, ingrown DEFINITIONS21 toenail, dressings, burns, rash) b. Pressure over bony prominences or genitalia Risk for Autonomic Dysreflexia Risk for life-threatening uninhib- c. Heterotrophic bone ited response of the sympathetic nervous system, post spinal shock, d. Spasm in an individual with a spinal cord injury/lesion at T6* or above. e. Fractures Autonomic Dysreflexia Life-threatening uninhibited sympathetic f. Range of motion exercises response of the nervous system to a noxious stimulus after a spinal g. Wounds cord injury at T7 or above. h. Sunburn 6. Regulatory stimuli a. Temperature fluctuations NANDA TAXONOMY: DOMAIN 9—COPING/STRESS b. Extreme environmental temperatures TOLERANCE; CLASS 3—NEUROBEHAVIORAL STRESS 7. Situational stimuli NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; a. Positioning CLASS I—NEUROLOGIC MANAGEMENT b. Drug reactions (e.g., decongestants, sympathomimetics, vasoconstrictors, narcotic withdrawal) NOC: DOMAIN II—PHYSIOLOGIC HEALTH; c. Constrictive clothing (e.g., straps, stockings, shoes) CLASS J—NEUROCOGNITIVE d. Surgical procedure 8. Cardiac and/or pulmonary problems DEFINING CHARACTERISTICS21 a. Pulmonary emboli b. Deep vein thrombus A. Risk for Autonomic Dysreflexia B. Autonomic Dysreflexia An injury or lesion at T6 or above and at least one of the fol- 1. Pallor (below the injury) lowing noxious stimuli: 2. Paroxysmal hypertension (sudden periodic elevated blood 1. Neurologic stimuli pressure where systolic pressure is more than 140 mm Hg a. Painful or irritating stimuli below level of injury and diastolic is more than 90 mm Hg) 2. Urologic stimuli 3. Red splotches on skin (above the injury) a. Bladder distention 4. Bradycardia or tachycardia (pulse rate of less than 60 or b. Detrusor sphincter dyssynergia more than 100 beats per minute) c. Bladder spasm 5. Diaphoresis (above the injury) d. Instrumentation or surgery 6. Headache (a diffuse pain in different portions of the head e. Epididymitis and not confined to any nerve distribution area) f. Urethritis 7. Blurred vision g. Urinary tract infection 8. Chest pain h. Calculi 9. Chilling i. Cystitis 10. Conjunctival congestion j. Catheterization 11. Horner’s syndrome (contraction of the pupil, partial ptosis 3. Gastrointestinal stimuli of the eyelid, enophthalmos, and sometimes loss of sweat- a. Bowel distention ing over the affected side of the face) b. Fecal impaction 12. Metallic taste in mouth c. Digital stimulation 13. Nasal congestion d. Suppositories 14. Paresthesia e. Hemorrhoids 15. Pilomotor reflex (gooseflesh formation when skin is f. Difficult passage of feces cooled) g. Constipation h. Enema RELATED FACTORS21 i. Gastrointestinal system pathology j. Gastric ulcers A. Risk for Autonomic Dysreflexia k. Esophageal reflux The risk factors also serve as the related factors. l. Gallstones B. Autonomic Dysreflexia 4. Reproductive stimuli 1. Bladder distention a. Menstruation 2. Bowel distention b. Sexual intercourse 3. Lack of patient and caregiver knowledge c. Pregnancy 4. Skin irritation d. Labor and delivery e. Ovarian cyst RELATED CLINICAL CONCERNS f. Ejaculation 1. Spinal cord injury at T7 or above *Has been demonstrated in patients with injuries at T7 and T8. Copyright © 2002 F.A. Davis Company AUTONOMIC DYSREFLEXIA, RISK FOR AND ACTUAL 247 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Decreased Cardiac Output Dysreflexia occurs Impaired Skin Integrity, the nurse must be only in spinal cord–injured patients and represents extremely alert to the possible development of an emergency situation that requires immediate Autonomic Dysreflexia. In addition, one of the intervention. Decreased Cardiac Output may be defining characteristics of Autonomic Dysreflexia suspected because of the changes in blood is red splotches, which could lead to a pressure or arrhythmias41,42; but, if the patient has misdiagnosis of Risk for Impaired Skin Integrity. a spinal cord injury at T7 or above, Autonomic Urinary Retention Dysreflexia should be Dysreflexia should be considered first. suspected in patients with spinal cord injuries at Impaired Skin Integrity Occasionally symptoms of T7 or above who experience bladder spasms, Autonomic Dysreflexia are precipitated by skin bladder distention, or untoward responses to lesions such as pressure sores and ingrown or urinary catheter insertion or irrigation.43,44 Bowel infected nails.43 If the patient has a spinal cord distention or rectal stimulation may also lead to injury at T7 or above in combination with Dysreflexia. EXPECTED OUTCOME TARGET DATES Will actively cooperate in care plan to prevent development of dys- Autonomic Dysreflexia is a life-threatening response. For this rea- reflexia by [date]. son, the target date should be expressed in hours on a daily basis. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor vital signs, especially blood pressure, every 3–5 min Extreme rises in blood pressure are indicative of sympathetic until stable; then every hour for 24 h; then every 2 h for 24 h; nervous system stimulation and may lead to cerebrovascular then every 4 h around the clock. accident and cardiac problems. • Immediately locate source that may have triggered dysreflexia, Finding precipitating causes prevents worsening of condition and e.g., bladder distention (76–90 percent of all instances), bowel allows further prevention of dysreflexia. distention (8 percent of all instances),45–47 fractures, acute abdomen, narcotic withdrawal, pressure ulcers, childbirth, sunburn, invasive procedures below the level of the spinal cord injury, ingrown toenails, and poor patient positioning. • Explain to the patient reasons for procedures. Reduces anxiety. • Empty bladder slowly with straight catheter (do not use Credé’s Alleviates precipitating causes. maneuver or tap bladder45,46), or manually remove impacted feces from rectum as soon as possible. • Elevate head of bed 90 degrees immediately if not Creates orthostatic hypotension. contraindicated by spinal injury. • Send urine specimen to laboratory for culture and sensitivity. Assists in determining whether infection is a possible cause of episode. • Collaborate with physician regarding the administration of Facilitates lowering of blood pressure; encourages teamwork. emergency antihypertensive therapy. • Keep the patient warm; avoid chilling at all times. Decreases sensory nervous stimulation. • Monitor intake and output every hour for 48 h, then every 2 h Monitors adequate functioning of bowel and bladder, which are for 48 h; then every 4 h. Note time schedule and dates here. common causative factors for dysreflexia. • Collaborate with physician regarding daily monitoring of Maintains fluid balance, and prevents complications that could electrolyte balance. impact cardiovascular functioning. • Turn the patient and have him or her cough and deep breathe Alleviates precipitating causes. every 2 h on [odd/even] hour; keep in anatomic alignment. • Perform ROM (active or passive) every 4 h while awake at Alleviates precipitating causes; stimulates circulation and muscular [times]. Pad bony prominences. activity; decreases incidence of pressure ulcers. • Instruct the patient on isotonic exercises. Encourage the patient Increases circulation and prevents complications of immobility. to perform isotonic exercises at least every 2 h on [odd/even] hour. (continued) Copyright © 2002 F.A. Davis Company 248 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Instruct on bladder and bowel conditioning. Monitor for Eliminates the two primary precipitating causes. bladder and bowel distention every 4 h at [times]. • Catheterize as necessary; use rectal tube if not contraindicated Eliminating precipitating causes. to assist with flatus reduction. • Provide appropriate skin care each time the patient is turned. Prevents and monitors for pressure ulcers. Monitor skin integrity at least once per shift at [times]. • Maintain adequate food and fluid balance on a daily basis. Assists in avoiding constipation. • Involve the family in care such as positioning, feeding, and Assists in teaching and preparing of the family for home care. exercising. • Be consistent and supportive in approach. Decreases anxiety and instills confidence in caregivers. • Use abdominal binders and antiembolic stockings as needed. Assists in preventing precipitating causes through providing cardiovascular support. • Administer medications as required. Medication therapy is generally instituted to help control blood pressure, control heart rate, and block excessive autonomic nerve transmission. • Encourage the family to use community resources. Make Cost-effective use of available resources; provides long-range referrals as soon as possible after admission. support for the patient and family. Child Health ACTIONS/INTERVENTIONS RATIONALES • Administer medications as required to help control the blood Assists in preventing seizures, and provides appropriate pressure at appropriate levels for age and weight. intervention to maintain pressure within desired ranges. • Monitor the pulse as needed and blood pressure every 5 min Basic monitoring for initial indications of problem development. until stable. Determine parameters for the patient according to the norms for age, site, and condition. • Monitor the family’s understanding and perception of the Assists in preventing misunderstandings and in identifying learning problem. Ensure that proper attention is paid to the family’s needs. needs for support during this emergency phase. • Teach the patient, as capable, and family routine for care, Education enhances care and provides an opportunity for care to including the prevention of infection (particularly urinary and be practiced in a supportive environment. integumentary). Women’s Health NOTE: This nursing diagnosis will pertain to women the same as to any other adult. The following precautions should be taken when the victim is pregnant. ACTIONS/INTERVENTIONS RATIONALES • Position the patient to prevent supine hypotension by: Keeps the weight of the uterus off the inferior vena cava. � Placing the patient on her left side if possible. � Using a pillow or folded towel under the right hip to tip to left. � If neck injury is suspected, placing the patient on a back board and then tipping the board to the left. • Start an intravenous line for replacement of lost fluid volume. The pregnant woman has 50 percent more blood volume and her vital signs may not change until there is a 30 percent reduction in circulating blood volume. • Monitor fetal status continuously. Monitor for uterine Basic data needed to ensure positive outcome. contractions at least once per hour.

Psychiatric Health The expected outcomes and nursing actions for the mental health client are the same as those for the adult patient. Gerontic Health The nursing actions for the gerontic patient are the same as those for Adult Health. Copyright © 2002 F.A. Davis Company AUTONOMIC DYSREFLEXIA, RISK FOR AND ACTUAL 249 Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client, family, and potential caregivers measures to Basic care techniques that can assist in preventing the occurrence prevent Autonomic Dysreflexia47–49: of dysreflexia. Promotes sense of control and autonomy. � Bowel and bladder routines � Prevention of skin breakdown (e.g., turning, transfer, or prevention of incontinence) � Use and care of indwelling urinary catheter � Prevention of infection • Assist the client and family in identifying signs and symptoms Provides for early recognition and intervention for problem. of Autonomic Dysreflexia47: � Teach the family how to monitor vital sign and how to recognize tachycardia, bradycardia, and paroxysmal hypertension. � Assist the client and family in identifying emergency referrals: Occurrence of this diagnosis is an emergency. This information (1) Physician provides the family with a sense of security by providing routes to (2) Emergency room and numbers of readily available emergency assistance. (3) Emergency medical system � Educate the client, family members, and potential caregivers Other treatments will not be effective until the stimulus is removed. about immediate elimination of the precipitating stimuli. � When an episode occurs, instruct the family and caregivers Decreases blood pressure and promotes cerebral venous return. to place head of the patient’s bed to an upright position. � Assist the client in obtaining necessary equipment to drain Allows for immediate removal of precipitating stimulus. the bladder or remove impactions at home. � Educate clients at risk for dysreflexia to be alert for signs and symptoms of Autonomic Dysreflexia during sexual encounters. Preparation for sexual intercourse should include a bowel and bladder check and disconnecting urinary drainage systems. • Teach the patient and family appropriate uses and side effects of Locus of control shifts from nurse to the client and family, thus medications as well as proper administration of the medications. promoting self-care. • Obtain available wallet-sized card that briefly outlines effective treatments in an emergency situation.50 Have the client carry this card with him or her at all times. Family members must be familiar with content and location of card. NOTE: Labeled a Treatment Card, this card contains information related to pathophysiology, common signs and symptoms, stimuli that trigger Autonomic Dysreflexia, problems, and recommended treatment. Copyright © 2002 F.A. Davis Company 250 ACTIVITY-EXERCISE PATTERN Autonomic Dysreflexia, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Can he or she restate signs and symptoms of dysreflexia? Does the patient immediately report any untoward signs and symptoms? Yes No Record data, e.g., restated all of Reassess using initial assessment factors. defining characteristics, had reported diaphoresis and headache. Record RESOLVED (may wish to use CONTINUE until the patient has been discharged from your service). Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., reports headache only when questioned; Did evaluation show another can restate only three of the defining problem had arisen? Yes characteristics. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company BED MOBILITY, IMPAIRED 251 Bed Mobility, Impaired 3. Major chest or abdominal surgeries 4. Malnutrition DEFINITION 5. Cachexia 6. Trauma Limitation of independent movement from one bed position to 7. Depression another.21 NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; HAVE YOU SELECTED CLASS 2—ACTIVITY/EXERCISE THE CORRECT DIAGNOSIS? NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; Impaired Physical Mobility Impaired Bed Mo- CLASS C—IMMOBILITY MANAGEMENT bility is a more specific diagnosis than Impaired NOC: DOMAIN I—FUNCTIONAL HEALTH; Physical Mobility. Certainly, an individual would CLASS C—MOBILITY have both diagnoses if he or she could not change his or her position in bed. Impaired Bed Mobility would be the priority diagnosis. DEFINING CHARACTERISTICS21 Activity Intolerance This diagnosis refers to 1. Impaired ability to turn side to side problems that develop when a person is engaged 2. Impaired ability to move from supine to sitting or sitting to in activities. The person with this diagnosis supine would be able to move freely while in bed. 3. Impaired ability to “scoot” or reposition self in bed Impaired Walking This diagnosis is specific to 4. Impaired ability to move from supine to prone or prone to the act of walking. This diagnosis, like Impaired supine Bed Mobility, could be considered a subset of Im- 5. Impaired ability to move from supine to long sitting or long sit- paired Physical Mobility. ting to supine EXPECTED OUTCOME RELATED FACTORS21 Will freely move self in bed by [date]. To be developed. TARGET DATES RELATED CLINICAL CONCERNS Improvement in mobility will require long-term intervention; 1. Any condition causing paralysis therefore, a feasible date for evaluating progress toward the out- 2. Arthritic conditions come would be 2 weeks. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Explain the movements to the patient, and encourage him or Promotes motivation and independence. her to participate as much as possible, even if it is only to control his or her head. • Move individual body segments. Reduces the effort required, and provides greater control. • Position the bed at the most comfortable height for you. Positions your center of gravity as close to the patient’s center of gravity as possible. • Position yourself close to the side of the patient. • Flex your hips and knees. Reduces strain on your back. • Side-to-side movement: When you slide rather than lift the patient toward you, the amount � Position one forearm under the back and one under the of energy required and the stress to your upper extremity and back patient’s head, and gently slide the upper body and head muscles are reduced.51 toward you. Do not lift the upper body; slide it on your forearms. Be sure to support the patient’s head. � Next, position your forearms under the patient’s lower trunk and just distal to the pelvis, and gently slide that body segment toward you. � Finally, position your forearms under the thighs and legs, and gently slide them toward you.51 (continued) Copyright © 2002 F.A. Davis Company 252 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Upward movement: Reduces friction between the extremities and the bed, and positions � Flex the patient’s hips and knees so that the feet rest flat on the patient so that he or she can assist by lifting the pelvis or the bed. Support the thighs with one or more pillows if the pushing with the extremities.51 patient is unable to maintain the proper position. � Face toward the patient’s head and stand approximately opposite the patient’s mid chest, with the foot that is farthest from the bed in from your other foot. � Support the patient’s head and upper trunk with your arms, Reduces the friction of the patient’s trunk on the bed, but does not and lift until the inferior angles of the scapulae clear the bed. place excessive strain or stress on the structures of your back.51 Your chest should be close to the patient’s chest. � Slide the lower trunk and pelvis approximately 6–10 in. To move the patient farther, reposition both yourself and the patient’s lower extremities and then repeat the process. � Ask for assistance as needed. � Use a lift sheet under the patient as needed.51 • Downward movement: � Partially flex the patient’s hips and knees. If necessary, use a pillow to support the thighs. � Position yourself approximately opposite to the patient’s waist or hips. � Cradle and lift the pelvis slightly before you slide the patient’s upper body and head downward. � Move the patient approximately 6–10 in. � Reposition yourself and the patient’s lower extremities if further movement is required.51 • Move to a side-lying position: � Initially position the patient close to the far edge of the bed. Be sure there is another person, a bedrail, or a wall to protect the patient from rolling off the bed. � Stand facing the patient so that you can roll (turn) him or her toward you to a side-lying position. � If you are rolling the patient to the right side, place the left lower extremity over the right. Place the left upper extremity over the chest, and place the right upper extremity in straight abduction. � Roll the patient toward you by pulling gently on the left posterior scapula and the left posterior pelvis. Do not use the upper or lower extremity to initiate the roll. � When the patient is in the side-lying position, flex the hips and knees and place a pillow under the head, between the knees and ankles, and along the front and back of the trunk. Position the downmost upper and lower extremities for comfort.51 • Move to a prone position: � Follow the actions for moving to a side-lying position, but position the arm over which the patient will roll either close along his or her side with the shoulder externally rotated, elbow straight, palm up, and the hand tucked under the pelvis, or with the shoulder flexed so that the arm rests next to the ear with the elbow straight. � Make sure there is enough room on the bed to roll the patient onto a prone position. If there is not, roll the patient onto the side-lying position, then move the patient backward before you complete the move to the prone position.51 • Move to a supine position from a prone position: � Follow the actions for moving to a prone position, except reverse the sequence.51 • Move to a sitting position: Do not allow the patient to sit unattended or without support. Some patients may experience vertigo or syncope when they are moved quickly from a supine to a sitting position. Other patients may lack sufficient strength or balance to remain sitting without some form of support.51 (continued) Copyright © 2002 F.A. Davis Company BED MOBILITY, IMPAIRED 253 (continued) ACTIONS/INTERVENTIONS RATIONALES � Move the patient close to one edge of the bed and flex the hips and knees with the feet flat on the bed. � Fold the arms across the chest unless they will be used to elevate the trunk or to hold onto your upper back. � Place one or both of your arms under the patient’s upper back and head, and elevate the trunk until a sitting position is attained. � Pivot the patient by supporting under the thighs and behind the back to a short sitting or dangle position.51 • Move to a supine position, patient sitting: � Reverse the sequence of actions described in the preceding section to move from a supine to a sitting position.51 Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributing factors within the client’s A complete ongoing assessment provides the primary database for developmental capacity. individualization of care. • Identify priorities of basic physiologic functions to be stabilized Stabilization of basic physiologic status must be considered for and considered as related to movement: tolerance and safety. � Respiratory � Cardiovascular � Neurologic � Orthopedic � Urologic � Integumentary • Determine need for assistive devices. Realistic support may depend on orthotics, braces, splints, or other mechanical devices for safety. • Assess teaching needs regarding mobility actions and Appropriate planning will offer greater likelihood of safe and instructions for the client, family, or staff who will assist in consistent efforts. mobility activities. • Coordinate efforts for other health team members. The nurse is best suited to provide consistent and safe planning of care with all health team members. • Determine the need for restraints of the client, and seek Appropriate attention to safety is paramount. appropriate orders if indicated. • Provide ongoing assessment with documentation of the client’s Ongoing timely assessment ensures safety and prevents injury. tolerance of mobility activities as often as the patient’s status dictates. • Provide developmentally appropriate diversionary activities. Engagement in preferred activities enhances the likelihood of cooperation by the client. • Safeguard areas of vulnerability while movement occurs, such Caution to entire body will best

help prevent further injury. as burns, traumatized limb, or surgical site. Women’s Health The nursing actions for Women’s Health are the same as those for Adult Health. Psychiatric Health Refer to Adult Health for interventions and rationales related to this diagnosis. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Consult with occupational therapist and physical therapist for Facilitates mobility efforts the client may be able to support.52 adaptive equipment to support the client while in bed (such as trapeze, transfer enabler, and foam support blocks). • Ensure that adaptive equipment is maintained in proper Ensures that safety needs are met. functioning order. (continued) Copyright © 2002 F.A. Davis Company 254 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Implement pressure-reducing devices, such as therapeutic Older adults are at high risk for pressure ulcers because of skin mattresses or mattresses with removable sections, to prevent fragility, changes in sensation, and altered nutrition.53 problems with skin integrity. • Schedule turning and position changes according to the client’s Depending on the individual client’s health status, turning at the tolerance to pressure. (Determined for each individual based on usually prescribed interval of q 2 h may not be sufficient to reduce general condition and risk for pressure ulcer development.) risk for pressure ulcers.53 • Initiate ROM interventions (active or passive) on a daily basis. Maintains joint mobility and prevents contractures.54 Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client in obtaining necessary durable medical equipment to facilitate independent movement and assisted movement (e.g., over-bed trapeze, hospital bed with siderails, and sliding board). • Educate the client, family, and caregivers in the correct use of equipment to facilitate independent movement and assisted movement (e.g., over-bed trapeze, hospital bed with siderails, and sliding board). • Instruct the caregivers in the proper use of draw sheets to Minimizes risk of injury to the client and caregiver. reposition the client rather than dragging the client or using poor body mechanics to assist in repositioning. • Assist the client in obtaining necessary supplies to prevent Prevents deep vein thrombosis. thrombus formation due to immobility, such as thromboembolic stockings or pneumatic devices. • Encourage ROM exercises to promote strength. Improves circulation and motor tone. • Teach the client regarding proper body mechanics. Prevents further injury. • As the client begins to progress in his or her efforts toward Promotes independence while protecting from further injury. independent mobility, the nurse provides minimal assistance from the weak side, supporting the unaffected side. Copyright © 2002 F.A. Davis Company BED MOBILITY, IMPAIRED 255 Bed Mobility, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient move self in bed? Yes No Record data, e.g., changes position Reassess using initial assessment factors. in bed with no assistance. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can only turn from side to back. Did evaluation show another Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 256 ACTIVITY-EXERCISE PATTERN Breathing Pattern, Ineffective 12. Spinal cord injury 13. Body position DEFINITION 14. Neurologic immaturity 15. Respiratory muscle fatigue Inspiration and/or expiration that does not provide adequate ventilation.21 RELATED CLINICAL CONCERNS NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 1. Chronic obstructive or restrictive pulmonary disease CLASS 4—CARDIOVASCULAR/PULMONARY 2. Pneumonia RESPONSE 3. Asthma 4. Acute alcoholism (intoxication or overdose) NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 5. Congestive heart failure CLASS K—RESPIRATORY MANAGEMENT 6. Chest trauma NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 7. Myasthenia gravis CLASS E—CARDIOPULMONARY DEFINING CHARACTERISTICS21 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? 1. Decreased inspiratory and/or expiratory pressure 2. Decreased minute ventilation Ineffective Airway Clearance Ineffective 3. Use of accessory muscles to breathe Airway Clearance means that something is 4. Nasal flaring blocking the air passage, but when air gets to 5. Dyspnea the alveoli, there is adequate gas exchange. 6. Altered chest excursion In Ineffective Breathing Pattern, the 7. Shortness of breath ventilatory effort is insufficient to bring in 8. Assumption of three-point position enough oxygen or to get rid of sufficient 9. Pursed-lip breathing amounts of carbon dioxide. However, air is 10. Prolonged expiration phase able to freely move through the air passages. 11. Increased anterior-posterior chest diameter Impaired Gas Exchange This diagnosis 12. Respiratory rate (adults [age 14 or older], 11 or 24; infants, indicates that enough oxygen is brought into 25 or 60; ages 1 to 4, 20 or 30; ages 5 to 14, 15 or the respiratory system, and the carbon 25) dioxide that is produced is exhaled, but 13. Depth of breathing (adults, tidal volume [VT] 500 mL at rest; there is insufficient exchange of oxygen and infants, 6 to 8 mL/kilo) carbon dioxide at the alveolar-capillary 14. Timing ratio level. There is no problem with either the 15. Orthopnea ventilatory effort or the air passageways. The 16. Decreased vital capacity problem exists at the cellular level. RELATED FACTORS21 1. Hyperventilation EXPECTED OUTCOME 2. Hypoventilation syndrome 3. Bone deformity Will demonstrate an effective breathing pattern by [date] as evi- 4. Pain denced by (specify criteria here, for example, normal breath sounds, 5. Chest wall deformity arterial blood gases within normal limits, no evidence of cyanosis). 6. Anxiety 7. Decreased energy or fatigue TARGET DATES 8. Neuromuscular dysfunction 9. Musculoskeletal impairment Evaluation should be made on an hourly basis, because this diag- 10. Perception or cognition impairment nosis has the potential to be life-threatening. After the patient has 11. Obesity stabilized, target dates can be spaced further apart. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Administer oxygen as ordered. Maintains or improves arterial blood gases (ABGs); reduces anxiety. • Monitor baseline respiratory data: Basic monitoring of overall condition and its related progress or lack � Respiratory rate and pattern of progress. (continued) Copyright © 2002 F.A. Davis Company BREATHING PATTERN, INEFFECTIVE 257 (continued) ACTIONS/INTERVENTIONS RATIONALES � Use of intercostal and accessory muscles � Position of comfort � Nares for flaring � Grunting or related noises such as stridor � Coughing; nature of secretions � Breath sounds � Related vital signs, especially apical pulse and blood pressure � Aids required for respiration and airway maintenance � Skin color, hydration, and elimination � Arterial blood gases as ordered � Appropriate related equipment, such as arterial line or IV � Oxygen administration per order � Documentation of all of the above • Collaborate with physician on monitoring of blood gases; report ABGs are important indicators of ventilatory effectiveness. abnormal results immediately. Promotes team approach to planning. • Perform nursing actions to maintain airway clearance. (See Maintains a patent airway for gas exchange. Ineffective Airway Clearance; enter those orders here.) • Reduce chest pain using noninvasive techniques and analgesics. Promotes chest expansion. • Maintain appropriate attention to relief of pain and anxiety via positioning, suctioning, and administration of medications as ordered. • Maintain appropriate caution for possible side effects of respiratory depression for specific medications such as morphine or Valium. • Raise head of bed 30 degrees or more if not contraindicated. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion. • Instruct in diaphragmatic deep breathing and pursed-lip Promotes lung expansion and slightly increases pressure in the breathing. Have the patient return-demonstrate and perform airways, allowing them to remain open longer; increases these activities at least every hour. oxygenation and exhalation of carbon dioxide. • Reduce fear and anxiety by spending at least 15 min every 2 h Reduces tension and stress; reduces oxygen demand and work of on [odd/even] hour with the patient. breathing. • Administer or assist with IPPB or CPAP as ordered. Remain Promotes expansion of airways and exchange of gases; staying with with the patient during treatment. the patient reduces anxiety. • Turn every 2 h on [odd/even] hour. Promotes mobility of any secretions and promotes lung expansion. • Encourage the patient’s mobility as tolerated (see Impaired Promotes tolerance for activities and helps with lung expansion and Physical Mobility). ventilation. • Instruct the patient in effects of smoking, air pollution, etc., Knowledge will assist the patient to avoid harmful environments prior to discharge, on breathing pattern. and to protect himself or herself from the effects from such activities. • Provide teaching based on needs of the patient and family Reduces anxiety; starts appropriate home care planning; assists the regarding: family in dealing with health care system. � Illness � Procedures and related nursing care � Implications for rest and relief of anxiety secondary to respiratory failure � Advocacy role Child Health ACTIONS/INTERVENTIONS RATIONALES • Maintain appropriate emergency equipment in an accessible Standard accountability for emergency equipment and treatment is place. (Specify actual size of endotracheal tube for the infant, basic to patient care and especially so when risk factors are child, or adolescent, tracheotomy set size, and suctioning increased. catheters or chest tube for size of the patient.) • Allow at least 5–15 min per shift for the parents and child to Appropriate time for venting may be hard to determine, but efforts verbalize concerns related to illness. to do so demonstrates valuing of patient and family needs and serves to reduce anxiety. • Determine perception of illness by the patient and parents. How the parents and child see (perceive) the patient’s problem provides meaningful data that serve to ensure sensitivity in care and provides information regarding teaching needs. Provides cues to (continued) Copyright © 2002 F.A. Davis Company 258 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES questions regarding continued implementation of therapeutic regimen. • Include the parents in care of the child as appropriate, to Parental involvement is critical in maintaining emotional bonds include comfort measures, assisting with feeding, and the like. with the child. Also augments sense of contributing to the child’s care, with opportunities for mastering the skills in a supportive environment. • Collaborate with appropriate related health team members Appropriate coordination of services will best meet the patient’s as needed. needs with attention to the patient’s individuality. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient and significant other in identifying lifestyle Increased cardiovascular fitness supports increased respiratory changes that may be required to prevent Ineffective Breathing effectiveness. Pattern during pregnancy, e.g., stopping smoking or avoiding crowds during influenza epidemics. • Develop exercise plan for cardiovascular fitness during pregnancy. • Teach the patient to avoid wearing constrictive clothing during Any constriction contributes to further breathing difficulties, and pregnancy. breathing becomes more difficult as the expanding uterus and abdominal contents press against the diaphragm.55 • Teach and encourage the patient to practice correct breathing Assists in preventing hyperventilation. techniques for labor. • During the latter stages of pregnancy, encourage the patient to: During this stage, the chest cavity has less room to expand because � Walk up stairs slowly. of the enlarging uterus.56 � Lie on left or right side, to get more oxygen to the fetus. � Position herself in bed with pillows for optimum comfort Often edema of the latter stage of pregnancy causes “stuffy” noses and adequate air exchange. and full sinuses. � Take frequent rest breaks during the workday. • Carefully monitor maternal respiration during the laboring Analgesics and anesthesia can cause maternal hypoxia and reduce process. fetal oxygen. • If prolonged decrease in fetal heart tone (FHT) immediately prior to delivery, administer pure oxygen (10–12 L/min) to the mother before delivery and until cessation of pulsation in cord. • Evaluate and record the respiratory status of the newborn infant: Basic care measures to ensure effective respiration in the newborn � Determine the 1-min Apgar score. infant. � Suction and clear mouth and pharynx with bulb syringe. � Avoid deep suctioning if possible. • Dry excess moisture off the infant with towel or blanket. Helps stimulate the infant; prevents evaporative heat loss. • Stimulate (if necessary), using firm but gentle tactile stimulation: � Slapping sole of foot � Rubbing up and down spine � Flicking heel • Place the infant in warm environment: � Place the infant under radiant heat warmer. � Place the infant next to the mother’s skin � Cover the infant’s head with stocking cap. � Cover both the mother and infant with warm blanket. • Determine and record the 5-min Apgar score. • Continue to evaluate the infant’s respiratory status

and be Basic protocol to care for the newborn who has respiratory prepared to act if necessary to resuscitate. Depending on the problems. infant’s response, the following nursing measures can be taken: � Administer warm, humid oxygen with face mask. � If no improvement, administer oxygen with bag and mask. � If no improvement, be prepared for: (1) Endotracheal intubation (2) Ventilation with positive pressure (3) Cardiac massage (4) Transport to neonatal intensive care unit Copyright © 2002 F.A. Davis Company BREATHING PATTERN, INEFFECTIVE 259 Psychiatric Health NOTE: The following orders are for Ineffective Breathing Pattern Related to Anxiety. When the diag- nosis is related to physiologic problems, refer to Adult Health nursing actions. ACTIONS/INTERVENTIONS RATIONALES • Monitor causative factors. Provides information on the client’s current status so interventions can be adapted appropriately. • Place the client in a calm, supportive environment. Anxiety is contagious, as is calm. A calm, reassuring environment can communicate indirectly to the client that the situation is safe and that the nurse can assist him or her in mobilizing their internal resources, thus facilitating the client’s sense of control. • Maintain a calm, supportive attitude, reassuring the client that you will assist him or her in maintaining control. • Give the client clear, concise directions. Anxiety can decrease the client’s ability to focus on and understand a complex presentation of information. • Have the client maintain direct eye contact with nurse. Modulate Communicates interest in the client, and assists the client in tuning based on the client’s ability to tolerate eye contact. Should not out extraneous stimuli. be done in a manner that appears to “stare the client down.” • Instruct the client to take slow, deep breaths. Demonstrate Helps stimulate relaxation response. breaths to the client, and practice with the client. Provide the client with constant, positive reinforcement for appropriate breathing patterns. • Remain with the client until episode is resolved. Reassures the client of safety and security. • If the client does not respond to the attempts to control Rebreathing air with a higher carbon dioxide (CO2) content slows breathing, have the client breathe into a paper bag. the respiratory rate. • Distract the client from focus on breathing by beginning a deep Interrupts pattern of thought that reinforces anxiety and therefore muscle relaxation exercise that starts at the client’s feet. increases breathing difficulties. • Use successful resolution of a problematic breathing episode as Promotes the client’s self-esteem and perceived control; also an opportunity to teach the client that he or she can gain provides positive reinforcement for adaptive coping behaviors. conscious control over breathing and that these episodes are not out of his or her control. • Teach the client and significant others proper breathing Promotes perceived control and adaptive coping behaviors. techniques, to include: Provides information that will facilitate positive reinforcement � Maintaining proper body alignment from the support system, increasing the probability for the � Using diaphragmatic breathing (see Ineffective Airway success of the behavior change.57 Clearance for information on this technique) � Use of deep muscle relaxation before the onset of ineffective breathing pattern begins • Practice with the client diaphragmatic breathing twice a day Enhances relaxation response. for 30 min. Note practice times here. • Develop a plan with the client for initiating slow, deep breathing Early recognition of problematic situations facilitates the client’s when an ineffective breathing pattern begins. ability to gain control and utilize adaptive coping behaviors. • Identify with the client those situations that are most frequently Positive imagery promotes positive psychophysiologic responses associated with the development of ineffective breathing patterns, and enhances self-esteem, which promotes the possibility for a and assist him or her in practicing relaxation in response to positive outcome.34 these situations 1 time a day for 30 min. Note time of practice session here. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor respiratory rate, depth, effort, and lung sounds every Minimum database needed for this diagnosis. 4 h around the clock. • Because of age-related “air trapping,” have the patient focus on Decreased alveoli and decreased elasticity lead to air trapping, improving expiratory effort. Instruct the patient to inhale to the which results in hyperinflation of lungs. count of 1 and exhale for 3 counts.58 • Collaborate with occupational therapy and respiratory therapy Occupational therapist can teach the patient less energy-expanding regarding other measures to enhance respiratory function. means to complete activities of daily living. Respiratory therapist can assist the patient and family in learning how to perform pulmonary toileting at home. (continued) Copyright © 2002 F.A. Davis Company 260 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • In the event of a chronic Ineffective Breathing Pattern, refer the Provides long-term support for coping with problems; provides patient to a support group such as those sponsored by the updated information; provides role modeling from other group American Lung Association. members. • Instruct in relaxation techniques, e.g., guided imagery or May assist in decreasing the episodes of acute breathing problems progressive muscle relaxation, to reduce stress. in those with chronic Ineffective Breathing Pattern. • Where applicable, monitor for knowledge of proper medication Maximum benefit may be derived from proper drug administration use, especially if inhalers are a part of the therapy. and usage. Inhalers may be difficult to operate because of physical problems and lack of information regarding proper usage. Home Health NOTE: If this diagnosis is suspected when caring for a patient in the home, it is imperative that a physi- cian referral be obtained immediately. If the patient has been referred to home health care by a physi- cian, the nurse will collaborate with the physician in the treatment of the patient. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides for early recognition and intervention for problem. symptoms of Ineffective Breathing Pattern: � Cough � Sputum production � Fatigue � Respiratory status: cyanosis, dyspnea, rate � Lack of diaphragmatic breathing � Nasal flaring � Anxiety or restlessness � Impaired speech • Assist the client and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required in assisting to prevent ineffective breathing necessary lifestyle changes. pattern: � Stopping smoking � Prevention and early treatment of lung infections � Avoidance of known irritants and allergies � Practicing pulmonary hygiene: (1) Clearing bronchial tree by controlled coughing (2) Decreasing viscosity of secretions via humidity and fluid balance (3) Clearing postural drainage � Treatment of fear, anxiety, anger, depression, thorax trauma, or narcotic overdoses � Adequate nutritional intake � Stress management � Adequate hydration � Breathing techniques (diaphragmatic, pursed lips) � Progressive ambulation � Pain relief � Preventing hazards of immobility � Appropriate use of oxygen (dosage, route, and safety factors) • Teach the patient and family purposes, side effects, and proper administration techniques of medication. • Assist the client and family to set criteria to help them Locus of control shifts from nurse to the client and family, thus determine when calling a physician or other intervention is promoting self-care. required. • Teach the family basic CPR. Copyright © 2002 F.A. Davis Company BREATHING PATTERN, INEFFECTIVE 261 Breathing Pattern, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient demonstrating an effective breathing pattern according to stated criteria? Yes No Record data, e.g., normal breath Reassess using initial assessment factors. sounds, rate of 18, blood gases within normal limits. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., pCO2 increased, pO2 decreased, Did evaluation show another R rate 28 and shallow, nail problem had arisen? Yes beds and lips cyanotic. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 262 ACTIVITY-EXERCISE PATTERN Cardiac Output, Decreased 4. Inflammatory heart disease, for example, pericarditis 5. Hypertension DEFINITION 6. Shock 7. Chronic obstructive pulmonary disease (COPD) Amount of blood pumped by the heart is inadequate to meet meta- bolic demands of the body.21 NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; HAVE YOU SELECTED CLASS 4—CARDIOVASCULAR/PULMONARY THE CORRECT DIAGNOSIS? RESPONSE Ineffective Tissue Perfusion Decreased NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; Cardiac Output relates specifically to a heart CLASS N—TISSUE PERFUSION MANAGEMENT malfunction, whereas Ineffective Tissue Perfusion relates to deficits in the peripheral NOC: DOMAIN II—PHYSIOLOGIC HEALTH; circulation that have cellular-level impact. CLASS E—CARDIOPULMONARY Tissue perfusion problems may develop secondary to Decreased Cardiac Output, but DEFINING CHARACTERISTICS21 can also exist without cardiac output problems.59 In either diagnosis, close 1. Altered Heart Rate and/or Rhythm collaboration will be needed with medical a. Arrhythmias (tachycardia, bradycardia) practitioners to ensure the best possible b. Palpitations interventions for the patient. c. Electrocardiographic (ECG) changes 2. Altered Preload a. Jugular vein distention b. Fatigue c. Edema EXPECTED OUTCOME d. Murmurs Will exhibit no signs or symptoms of decreased cardiac output by e. Increased or decreased central venous pressure (CVP) [date]. f. Increased or decreased pulmonary artery wedge pressure (PAWP) g. Weight gain TARGET DATES 3. Altered Afterload Because the nursing diagnosis Decreased Cardiac Output is so life- a. Cold and/or clammy skin threatening, progress toward meeting the expected outcomes b. Shortness of breath and/or dyspnea should be evaluation at least daily for 3 to 5 days. If significant c. Prolonged capillary refill progress is demonstrated, then the target date can be increased to d. Decreased peripheral pulses 3-day intervals. Patients who develop this diagnosis should be re- e. Variations in blood pressure readings ferred to a medical practitioner immediately and transferred to a f. Increased or decreased systemic vascular resistance (SVR) critical care unit. g. Increased or decreased pulmonary vascular resistance (PVR) h. Skin color change 4. Altered Contractility ADDITIONAL INFORMATION a. Crackles Cardiac output (CO) refers to the amount of blood ejected from the b. Cough left ventricle into the aorta per minute. Cardiac output is equivalent c. Orthopnea or paroxysmal nocturnal dyspnea to the stroke volume (SV), which is the amount of blood ejected d. Cardiac output 4 L/min from the left ventricle with each contraction, times the heart rate e. Cardiac index 2.5 L/min (HR), or the number of beats per minute: f. Decreased ejection fraction, stroke volume index (SVI), and left ventricular stroke work index (LVSWI) CO  SV  HR g. S3 or S4 sounds The average amount of cardiac output is 5.6 L per minute. This 5. Behavioral and Emotional Factors amount varies according to the individual’s amount of exercise and a. Anxiety body size. b. Restlessness Cardiac output is dependent on the relationship between stroke volume and the heart rate. Cardiac output is maintained by com- RELATED FACTORS21 pensatory adjustment of these two variables. If the rate slows, the 1. Altered heart rate and/or rhythm time for ventricular filling (diastole) increases. This allows for an in- 2. Altered stroke volume crease in the preload and a subsequent increase in stroke volume. a. Altered preload If the stroke volume falls, the heart rate increases to compensate. b. Altered afterload Preload, contractility, and afterload affect stroke volume. c. Altered contractility Preload refers to the amount of stretching of the myocardial fibers. The fibers stretch as a result of the increase in the volume RELATED CLINICAL CONCERNS of blood delivered to the ventricles during diastole. The degree of myocardial stretch before contraction is preload. Preload is deter- 1. Congestive heart failure mined by the venous return and ejection fraction (amount of blood 2. Myocardial infarction left in the ventricle at the end of systole). Prolonged excessive 3. Valvular heart disease stretching leads to a decrease in cardiac output. Copyright © 2002 F.A. Davis Company CARDIAC OUTPUT, DECREASED 263 Contractility is a function of the intensity of the actinomycin link- The autonomic nervous system, through both the sympathetic ages. Increased contractility increases ventricular emptying and re- and parasympathetic nervous systems, predominantly influences sults in increased stroke volume. Contractility can be increased by the heart rate. The sympathetic fibers can increase both rate and sympathetic stimulation or by administration of such substances as force, whereas the parasympathetic fibers act in an opposite direc- calcium and epinephrine. tion. Other factors such as the central nervous system pressorecep- Afterload is the amount of tension developed by the ventricle dur- tor reflexes, cerebral cortex

impulses, body temperature, elec- ing contraction. The amount of peripheral resistance predomi- trolytes, and hormones also affect the heart rate, but the autonomic nantly determines the amount of tension. Excessive increases in the nervous system keeps the entire system in balance.60 afterload reduces stroke volume and cardiac output. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Place on cardiac monitor and continuously monitor cardiac Myocardial perfusion can be more accurately assessed. rhythm and rate. • Monitor, at least every 2 h on [odd/even] hour: Establishes baseline and allows for accurate monitoring of changes � Vital signs from baselines. � Chest and heart sounds � Apical-radial pulse deficit; pedal pulses � Pulse pressure � Other hemodynamic readings (e.g., wedge pressures, pulmonary artery pressure [PAP], pulmonary capillary wedge pressure [PCWP], central venous pressure [CVP]) � Neck vein filling � Peripheral edema (extremities, eyelids, sacral areas) � Level of consciousness � Activity intolerance � Mental status � Skin changes � Peripheral pulses � Liver position • Collaborate with physician regarding frequency of measurement Additional baseline data needed for accurate monitoring of of the following, and closely monitor results: condition. � Arterial blood gases � Electrolytes � Cardiac enzymes � Complete blood cell count � Electrolyte balance • Explain reasons for tests and monitoring to the patient as well as Decreases anxiety and promotes more accurate monitoring results. the role he or she plays in ensuring accurate results. • Administer oxygen and medications as ordered, and monitor Enhances myocardial perfusion and decreases workload. effects. • Monitor flow rate of oxygen. • Measure urinary output hourly. Fluid overload or underload can compromise cardiac output. • Measure and record intake and total at least every 8 h. Collaborate with physician regarding limitation of intake. • Monitor pain, and institute immediate relief measures. Pain can increase cardiac output; relief measures also decrease anxiety. • Keep siderails up and bed in low position, particularly during Basic patient safety. periods of altered mental status. • Weigh daily at [time] and in same weight clothing. Helps determine changes in fluid volume. • Provide skin care at least every 2 h on [odd/even] hour: Promotes tissue perfusion; decreases pressure area, thus decreasing � Change position and support in anatomic alignment. the likelihood of impaired tissue integrity. � Elevate edematous extremities, and use measures such as a bed cradle to keep pressure off edematous parts. � Use sheepskin, egg crate mattress, or alternating air mattress under the patient. � Keep linens free of wrinkles. � Keep skin clean and dry. (continued) Copyright © 2002 F.A. Davis Company 264 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Avoid shearing forces when moving the patient. � Use cornstarch on bed and skin to facilitate the patient’s movement. • Do ROM exercises at least once per shift, and position the Promotes circulation; reduces consequences of impaired mobility. patient carefully. Careful positioning assists breathing and avoids pressure. • Monitor intravenous therapy: Prevents fluid overload or underload. Monitors IV site for patency � Flow rate of veins and for presence of infection. � Insertion site • Provide adequate rest periods: Decreases stress on already stressed circulatory system. � Schedule at least one 5-min rest after any activity. � Schedule 30- to 60-min rest period after each meal. • Limit visitors and visiting time. Explain need for restriction to the patient and significant others. If presence of significant other promotes rest, allow to stay beyond time limits. • Monitor bowel elimination, abdominal distention, and bowel Avoids straining and Valsalva maneuver, which compromises sounds at least once per shift during waking hours. Collaborate cardiac output. with physician regarding stool softener. • Assist the patient with stress management and relaxation Decreases anxiety and promotes cardiac output. techniques every 4 h while awake (state times here). Support the patient in usual coping mechanisms. • Plan to spend at least 15 min every 4 h providing emotional Decreases anxiety. support to the patient and significant others. • Collaborate with dietitian regarding dietary restrictions when These dietary factors can compromise cardiac output. developing plan of care, and reinforce prior to discharge (e.g., sodium, fluids, calories, and cholesterol). • Collaborate with occupational therapist and the family Promotes collaboration and holistic care. regarding diversional activities. Refer to: � Physical therapist for home exercise program � Visiting nurse service Child Health ACTIONS/INTERVENTIONS RATIONALES • Provide in-depth monitoring and documentation related to the These factors constitute the basic measures utilized in monitoring following: for decompensation of cardiac status. Closely related are respiratory � Ventilator, if applicable: function, hydration status, and hemodynamic status. (1) If continuous positive airway pressure (CPAP), adjust setting according to physician order (2) Peak pressure as ordered (3) O2 percentage desired as ordered � Intake and output hourly and as ordered. Notify physician if below 10 mL/h or as specified for size of the infant or child � Excessive bleeding. If in postoperative status, notify physician if more than 50 mL/h or as specified. � Tolerance of feedings � Notify physician for: (1) Premature ventricular contractions (PVCs) or other arrhythmias (2) Limits of pulse, respiratory rate, output criteria as specified for the individual patient � Use caution in the administration of medications as ordered, especially digoxin: (1) Have another RN check dose and medication order. (2) Validate and document the heart rate to be greater than specified lower limit parameter (e.g., 100 for infant) before administering. � Document if medication withheld because of heart rate. � Monitor for signs and symptoms of toxicity, e.g., vomiting. (continued) Copyright © 2002 F.A. Davis Company CARDIAC OUTPUT, DECREASED 265 (continued) ACTIONS/INTERVENTIONS RATIONALES � Ensure potassium maintenance. Collaborate with physician regarding frequency of serum potassium measurement, and immediately report results. � Maintain digitalizing protocol. � Make sure that the parents understand the patient’s status and treatment. � Monitor the patient’s response to suctioning, x-ray, or other procedures. • Ensure availability of crash cart and emergency equipment as Standard nursing care includes availability and appropriate use of needed, to include: equipment and medications in event of cardiac arrest. Anticipation � Cardiac or emergency drugs for need of equipment with a child in high-risk status is required. � Defibrillator � Ambu bag (pediatric or infant size) � Appropriate suctioning equipment • Allow time for the parents to voice concern on a regular basis. Verbalization of concerns helps reduce anxiety. Attempting to set Set aside 10–15 min per shift for this purpose. aside time for this verbalization demonstrates the value it holds for the patient’s care. • Encourage parental input in care, such as with feeding, Parental input assists in meeting the parent’s and child’s emotional positioning, and monitoring intake and output as appropriate. needs and supports the care given by health care personnel. This action also allows for learning essential skills in a supportive environment. • Encourage the patient, as applicable, to participate in care. Self-care enhances sense of autonomy and empowerment. • Allow for sensitivity to time in understanding of diagnosis. The Abstract aspects of an illness often prove more difficult to grasp. seemingly abstract nature of underlying cardiac physiology, Congenital cardiac anomalies are often complex in nature, which especially in noncyanotic heart disease, can be confusing. requires health care personnel to use consistent terms and offer appropriate aids to depict key issues of anatomy. • Support the parents in usual appropriate coping mechanisms. Emotional security may be afforded by encouragement of usual coping mechanisms for age and developmental status. • Maintain appropriate technique in dressing change (asepsis and Standard care requires universal precautions, which minimize risk cautious handwashing). factors for infection. • Limit visitors in immediate postoperative status as applicable. Visitation may prove overwhelming to all when unlimited in immediate postoperative period. Remember that numerous nursing- medical therapies must be attended to during this time also. • Help reduce patient and parental anxiety by touching and Comforting allows the parent and child to feel more secure and allowing the patient to be held and comforted. decreases feeling of intimidation the parents might perceive from numerous pieces of equipment and activity. Human caring helps offset high tech. • Provide teaching with sensitivity to patient and parental needs Individualized teaching with appropriate aids will most likely serve regarding equipment, procedures, or routines, e.g., use a doll to reinforce desired learning and enlist the patient’s cooperation. for demonstration with toddler. • Encourage the parents to meet the parents of similarly involved Sharing with similarly involved clientele or families affords a sense cardiac patients. of unity, hope, and affirmation of the future far beyond what nurses or others may offer. • Address need for the parents to continue with activities of daily Aim should be for normalcy within parameters dictated by the living with confidence regarding knowledge of restrictions in child’s condition. Strive to refrain the family from labeling the the child’s status. child or encouraging the child to become a “cardiac cripple.” Women’s Health NOTE: Caution the patient never to begin a new vigorous exercise plan while pregnant. Teach the pa- tient to exercise slowly, in moderation, and according to the individual’s ability. A good rule of thumb is to use moderation and, with the consent of the physician, continue with the pre-pregnant estab- lished exercise plan. Most professionals discourage aerobics and hot tubs or spas because of the heat. It is not known at this time if overheating by the mother is harmful to the fetus. ACTIONS/INTERVENTIONS RATIONALES • Assist the patient with relaxation techniques. Assists in stress reduction. • Assist in developing an exercise plan for cardiovascular fitness Assists in increasing cardiovascular fitness during pregnancy. during pregnancy. Some good exercises are: � Swimming � Walking (continued) Copyright © 2002 F.A. Davis Company 266 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Bicycling � Jogging (If the patient has done this before and is used to it, jogging is probably not harmful, but remember that during pregnancy joints and muscles are more susceptible to strain. If the patient feels pain, fatigue, or overheating, she should slow down or stop exercise.) • Refer the patient to support groups that understand the physiology of pregnancy and have developed exercise programs based on this physiology, such as swimming classes for pregnant women at the local YWCA, childbirth education classes, or exercise videotapes specifically directed and produced for use during pregnancy. • Teach the patient and significant others how to avoid “supine The expanded uterus causes pressure on the large blood vessels. hypotension” during pregnancy (particularly the later stages). • Prior to the start of labor, encourage the patient to attend childbirth education classes to learn how to work with her body during labor. • During the second stage of labor61–63: � Allow the patient to assume whatever position aids her in the second stage of labor (i.e., upright, squatting, kneeling position, the use of birth balls, etc.). � Provide the patient with proper physical support during the second stage of labor. This support might include allowing the partner or support person to sit or stand beside her and support her head or shoulders, or behind her supporting her with his or her body. The partner might also stand in front of her, allowing her to lean on his or her neck. The patient may also use a birthing bed or chair, pillows, over-the-bed table, or bars. • Do not urge the woman to “push, push” or to hold breath Avoids straining and the Valsalva maneuver. during the second stage of labor. Allow the woman to bear down with her contractions at her own pace: � Encourage spontaneous bearing down only if fetal head has not descended low enough to stimulate Ferguson’s reflex. � Encourage the mother to push when she feels the urge and to rest between contractions. � Discourage prolonged maternal breath-holding (longer than Breath-holding involves the Valsalva maneuver. Increased 6–8 s) during pushing. intrathoracic pressure due to a closed glottis causes a decrease in � Assist the mother to accomplish 4 or more pushing efforts cardiac output and blood pressure. The fall in pressure causes a per contraction. decrease in placental perfusion, causing fetal hypoxia.55,64 � Support the mother’s efforts in pushing, and validate the normalcy of sensations and sounds the mother is verbalizing. (These sounds may include grunting, groaning, and exhaling during the push or breath-holding less than 6 s.) Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor risk factors: Early identification and

intervention helps ensure better outcome. � Medications � Past history of cardiac problems � Age � Current condition of the cardiovascular system � Weight � Exercise patterns � Nutritional patterns � Psychosocial stressors • Monitor every [number] hours (depends on level or risk, can be Basic database for further intervention. anywhere from 2–8 h) the client’s cardiac functioning (list times to observe here): � Vital signs � Chest sounds (continued) Copyright © 2002 F.A. Davis Company CARDIAC OUTPUT, DECREASED 267 (continued) ACTIONS/INTERVENTIONS RATIONALES � Apical-radical pulse deficit � Mental status • Report alterations to medical practitioner immediately. • If acute situation develops, notify medical practitioner and implement adult health nursing actions. • If the client’s condition or other factors necessitate the client’s remaining in the mental health area beyond the acute stage, refer to adult health nursing actions for care on an ongoing basis. This is not recommended because of the lack of equipment and properly trained staff to care for this situation on most specialized care units. • If the client is placed on unit while in the rehabilitation stage of Promotes the client’s perceived control and supports self-care this diagnosis, implement the following nursing actions: activities. (Discuss with the client current rehabilitation schedule, and record special consideration here.) • Provide appropriate rest periods following activity. This varies Prevents excessive stress on the cardiovascular system, and according to the client’s stage in rehabilitation. Most common prevents fatigue. times of needed rest are after meals and after any activity (note specific limits here). • Assist the client with implementation of exercise program. List Promotes cardiovascular strength and well-being. types of activity, time spent in activity, and times of activity here. Also list special motivators the client may need, such as a companion to walk for 30 min 3 times a day at [times]. • Provide diet restrictions, e.g., low sodium, low calorie, low fat, Decreases dietary contributions to increased risk factors. low cholesterol, or fluid restrictions. • Monitor intake and output each shift. Medications can affect fluid balance, and excessive fluid can increase demands on the cardiovascular system. • Assess for and teach the client to assess for: Increases the client’s perceived control, and promotes early � Potassium loss (muscle cramps) recognition and treatment of problem. � Chest pain � Dyspnea � Sudden weight gain � Decreased urine output � Increased fatigue • Monitor risk factors, and assist the client in developing a plan to Increases the client’s perceived control, and decreases risk for reduce these, e.g., smoking, obesity, or stress. Refer to further damage to the cardiovascular system. appropriate nursing diagnosis for assistance in developing interventions. • Spend 30 min twice a day teaching the client deep muscle Relaxation decreases stress on the cardiovascular system. relaxation and practicing this process (list times here). • Discuss with the patient’s support system the lifestyle alterations that may be required. • Develop stress reduction program with the client, and provide Enhances possibility for continuation of behavior change.57 necessary environment for implementation. This could include massage therapy, meditation, aerobic exercise as tolerated, hobbies, or music (note specific plan here). Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the older adult for atypical signs of pain, such as The older adult may experience physiologic and psychological alterations in mental status, anxiety, or decreasing functional alterations that affect their response to pain.65 capacity. • Monitor for possible side effects of diuretic therapy. Older adults may have excessive diuresis on normal diuretic dosage. • Review the health history for liver or kidney disease in patients To avoid complications, dosages of diuretics may need to be on diuretic therapy. adjusted in those with preexisting kidney or hepatic disease. • Whenever possible, give diuretics in the morning. Decreases problems with nocturia and consequent distributed sleep-rest pattern or risk for injury from falls. • Teach proper medication usage, e.g., dosage, side effects, Basic safety for medication administration. dangers related to missed doses, and food/drug interactions. (continued) Copyright © 2002 F.A. Davis Company 268 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach patients who are on potassium-wasting diuretics: � The need for potassium replacement � Foods that are high in potassium, e.g., bananas � Signs and symptoms of potassium depletion • Assist the patient and/or family to determine environmental Assists in conservation of energy and balancing oxygen demands conditions that may need to be adapted to promote energy. with resources. Home Health NOTE: If this diagnosis is suspected when caring for a client in the home, it is imperative that a physi- cian referral be obtained immediately. If the client has been referred to home health care by a physician, the nurse will collaborate with the physician in the treatment of the client. ACTIONS/INTERVENTIONS RATIONALES • Teach the patient and significant others: Provides for early recognition and intervention for problem. � Risk factors, e.g., smoking, hypertension, or obesity � Medication regimen, e.g., toxicity or effects � Need to balance rest and activity � Monitoring of: (1) Weight daily (2) Vital signs (3) Intake and output � When to contact health care personnel: (1) Chest pain (2) Dyspnea (3) Sudden weight gain (4) Decreased urine output (5) Increased fatigue � Dietary adaptations, as necessary: (1) Low sodium (2) Low cholesterol (3) Caloric restriction (4) Soft foods • Assist the patient and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Eliminating smoking � Cardiac rehabilitation program � Stress management � Weight control � Dietary restrictions � Decreased alcohol � Relaxation techniques � Bowel regimen to avoid straining and constipation � Maintenance of fluid and electrolyte balance � Changes in role functions in the family � Concerns regarding sexual activity � Monitoring activity and responses to activity (Note: Level of damage to left ventricle should be determined before exercise program is initiated.66) � Providing diversional activities when physical activity is restricted (see Deficient Diversional Activity) � Pain control • Teach the family basic CPR. Locus of control shifts from nurse to the client and family, thus promoting self-care. • Teach the client and family purposes and side effects of medications and proper administration techniques. • Teach the client and family to refrain from activities that increase the demands on the heart, e.g., snow shoveling, lifting, or Valsalva maneuver. • Assist the client and family to set criteria to help them determine when calling a physician or other intervention is required. • Consult with or refer to appropriate assistive resources as Provides additional support for the client and family, and uses indicated. already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company CARDIAC OUTPUT, DECREASED 269 Cardiac Output, Decreased FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient have any signs or symptoms of decreased cardiac output? Yes No Reassess using initial assessment factors. Record data, e.g., apical and radial pulse both 74; no rales or rhonchi in lungs; skin warm and pink. Record RESOLVED (may wish to use CONTINUE until the patient is Is diagnosis validated? discharged from your service). Delete nursing diagnosis, expected outcome, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., pO2 remains below normal, pCO2 still increased; mental confusion present; continued Yes No remarks regarding “not getting enough air.” Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company 270 ACTIVITY-EXERCISE PATTERN Disuse Syndrome, Risk for 3. Closed head injury 4. Spinal cord injury or paralysis DEFINITION 5. Rheumatoid arthritis 6. Amputation A state in which an individual is at risk for deterioration of body 7. Cerebral palsy systems as the result of prescribed or unavoidable musculoskeletal inactivity.21 NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; HAVE YOU SELECTED CLASS 2—ACTIVITY/EXERCISE THE CORRECT DIAGNOSIS? NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; Activity Intolerance This diagnosis implies CLASS A—ACTIVITY AND EXERCISE MANAGEMENT that the individual is freely able to move but cannot endure or adapt to the increased NOC: DOMAIN I—FUNCTIONAL HEALTH; energy or oxygen demands made by the CLASS A—ENERGY MAINTENANCE movement or activity. Impaired Physical Mobility With this DEFINING CHARACTERISTICS21 (RISK FACTORS) diagnosis, the individual could move independently if something was not limiting 1. Severe pain the motion. Impaired Physical Mobility 2. Mechanical immobilization could very well be a predisposing factor to 3. Altered level of consciousness Risk for Disuse Syndrome. 4. Prescribed immobilization 5. Paralysis RELATED FACTORS21 EXPECTED OUTCOME The risk factors also serve as the related factors. Will exhibit no signs or symptoms of disuse syndrome by [date]. RELATED CLINICAL CONCERNS TARGET DATES 1. Cerebrovascular accident Disuse syndrome can develop rapidly after the onset of immobiliza- 2. Fractures tion. The initial target date, therefore, should be no more than 2 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributing factors to pattern of disuse. Can offset development of disuse syndrome or worsening of condition. • According to the patient’s status, determine realistic potential Improves planning and allows for setting of more realistic goals. and actual levels of functioning with regard to general physical condition: � Cognition � Mobility, head control, positioning � Communication, receptive and expressive, verbal or nonverbal � Augmentive aids for daily living • Turn and anatomically position the patient every 2 h on [odd/even] hour. • Perform active and passive ROM exercises to all joints at least Promotes circulation, prevents venous stasis, and helps prevent twice a shift while awake. State times here. thrombosis. • Teach the patient relaxation and pain reduction techniques Relaxes muscles and promotes circulation. every shift, and have the patient return-demonstrate. • Demonstrate and have the patient return-demonstrate isotonic Helps avoid syndrome; offsets complications of immobility. exercises. • Encourage the patient to perform isotonic exercises at least every 4 h at [state times here]. • Arrange daily activities with appropriate regard for rest as needed. • Maintain adequate nutrition and fluid balance on daily basis. Provides fluid and nutrient necessary for activity. (continued) Copyright © 2002 F.A. Davis Company DISUSE SYNDROME, RISK FOR 271 (continued) ACTIONS/INTERVENTIONS RATIONALES • Orient the patient to environment as necessary. Maintains mental activity and reality. • Monitor the patient and family for perceived and actual health Initiates appropriate home care planning. teaching needs, including: � Patient’s status � Patient’s daily care � Equipment required for the patient’s care � Signs or symptoms to be reported to physician � Medication administration, instructions, and side effects � Plans for follow-up • Refer to Impaired Physical Mobility for more detailed nursing actions. Child Health ACTIONS/INTERVENTIONS RATIONALES • Assist the family in development of an individualized plan of The family is the best source for individual preferences and needs care to best meet the child’s potential. as related to what daily living for the child involves. • Assist the family in identification of factors that will facilitate Identifies learning needs and reduces anxiety. Fosters a plan that progress as well as those factors that may hinder progress in can be adhered to if all involved participate in its development. meeting the child’s potentials. List those factors here, and assist Empowers the family. the family in planning how to offset factors that hinder progress and encourage factors that facilitate progress. • Encourage the patient and family to ventilate feelings that may Ventilation of feelings assists in reducing anxiety and promotes relate to disuse problem by scheduling of 15–20 min each learning about condition. nursing shift for this activity. • Assist the family in identification of support system for best Promotes coordination of care and cost-effective use of already possible follow-up care. available resources. Women’s Health This nursing diagnosis will pertain to women the same as to men. Refer to nursing actions for Risk for Ac- tivity Intolerance to meet the needs of women with the diagnosis of Risk for Disuse Syndrome. Psychiatric Health NOTE: The nursing actions in this section reflect the Risk for Disuse Syndrome related to mental health. This would include use of restraints and seclusion. If the inactivity is related to a physiologic or physical problem, refer to the Adult Health nursing actions. ACTIONS/INTERVENTIONS RATIONALES • Attempt all other interventions before considering immobilizing Promotes the client’s perceived control and self-esteem. the client. (See Risk

for Violence, Chap. 9, for appropriate actions.) • Carefully monitor the client for appropriate level of restraint Client safety is of primary importance while maintaining, as much necessary. Immobilize the client as little as possible while still as possible, the client’s perceived control and self-esteem. protecting the client and others. • Obtain necessary medical orders to initiate methods that limit Provides protection of the client’s rights. This should be done in the client’s physical mobility. congruence with the state’s legal requirements. • Carefully explain to the client, in brief, concise language, reasons High levels of anxiety interfere with the client’s ability to process for initiating the intervention and what behavior must be present complex information. Maintains relationship and promotes the for the intervention to be terminated. client’s perceived control. • Attempt to gain the client’s voluntary compliance with the Communicates to the client that staff has the ability to maintain intervention by explaining to the client what is needed and with control over the situation, and provides the client with an a “show of force” (having the necessary number of staff available opportunity to maintain perceived control and self-esteem. to force compliance if the client does not respond to the request). • Initiate forced compliance only if there is an adequate number Staff and client safety are of primary importance. of staff to complete the action safely (see Risk for Violence, Chap. 9, for a detail description of intervention with forced compliance). (continued) Copyright © 2002 F.A. Davis Company 272 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Secure the environment the client will be in by removing Provides safe environment by removing those objects the client harmful objects such as accessible light bulbs, sharp objects, could use to impulsively harm self. glass objects, tight clothing, metal objects, or shower curtain rods. • If the client is placed in four-point restraints, maintain Promotes client safety and communicates maintenance of one-to-one supervision. relationship while meeting security needs. • If the client is in seclusion or in bilateral restraints, observe the Ensures client safety. client at least every 15 min, or more frequently if agitated. (List observation schedule here.) • Leave urinal in room with the client or offer toileting every hour. Meets the client’s physiologic needs and communicates respect for the individual. • Offer the client fluids every 15 min while awake. • Discuss with the client his or her feelings about the initiation of Promotes the client’s regaining control, and clearly provides the immobility, and review at least twice a day the kinds of behavior client with alternative behaviors for coping. necessary to have immobility discontinued (note behaviors here). • When checking the client, let him or her know you are checking Promotes sense of security, and provides information about the by calling him or her by name and orienting him or her to day client’s mental status that will provide information for further and time. Inquire about the client’s feelings, and implement interventions. necessary reality orientation. • Provide meals at regular intervals on paper containers, providing Meets physiologic needs while maintaining client safety. necessary assistance (amount and type of assistance required should be listed here). • If the client is in restraints, remove restraints at least every Maintains adequate blood flow to the skin and prevents breakdown. 2 h one limb at a time. Have the client move limb through Maintains joint mobility and prevents contractures and muscle a full ROM and inspect for signs of injury. Apply lubricants atrophy. such as lotion to area under restraint to protect from injury. • Pad the area of the restraint that is next to the skin with Protects skin from mechanical irritation from the restraint. sheepskin or other nonirritating material. • Check circulation in restrained limbs in the area below the Early assessment and intervention prevent long-term damage. restraint by observing skin color, warmth, and swelling. Restraint should not interfere with circulation. • Change the client’s position in bed every 2 h on [odd/even] hour. Protects skin from ischemic and shearing pressure damage. Have the client cough and deep breathe during this time. Promotes normal clearing of airway secretions. • Place body in proper alignment to prevent complications and injury. Use pillows for support if the client’s condition allows. • If the client is in four-point restraints, place on stomach or side Prevents aspiration or choking. or elevate head of bed. • Place the client on intake and output monitoring to ensure that Promotes normal hydration, which prevents thickening of airway adequate fluid balance is maintained. secretions and thrombus formation.67 • Have the client in seclusion move around the room at least every Assesses the client’s risk for the development of orthostatic 2 h on [odd/even] hour. During this time, initiate active ROM hypotension. and have the client cough and take deep breaths. • Administer medications as ordered for agitation. • Monitor blood pressure before administering antipsychotic medications. • Have the client change position slowly, especially from lying to The combination of immobility and antipsychotic medications standing. can place the client at risk for the development of orthostatic hypotension. Slowing position change allows time for blood pressure to adjust and prevents dizziness and fainting. • Assist the client with daily personal hygiene. Gives the client a sense of control. • Have environment cleaned on a daily basis. Communicates respect for the client. • Remove the client from seclusion as soon as the contracted Promotes the client’s perception of control, and provides positive behavior is observed for the required amount of time. (Both of reinforcement for appropriate behavior. these should be very specific and listed here. See Risk for Violence, Chap. 9, for detailed information on behavior change and contracting specifics.) • Schedule time to discuss this intervention with the client and Promotes family understanding, and optimizes potential for his or her support system. Inform support system of the need positive client response.57 for the intervention and about special considerations related to visiting with the client. This information must be provided with consideration of the support system before and after each visit. Copyright © 2002 F.A. Davis Company DISUSE SYNDROME, RISK FOR 273 Gerontic Health Refer to the interventions provided in the Adult Health section of this diagnosis for additional appropri - ate interventions for the older adult. ACTIONS/INTERVENTIONS RATIONALES • Monitor for iatrogenesis, especially in the case of Although the regulations of the Omnibus Bill Reconciliation Act institutionalized elderly. (OBRA) require the least-restrictive measures and ideally restraint- free care, older adults in long-term care may be placed at risk for disuse syndrome secondary to geri-chairs, use of wheelchairs, and lack of properly functioning or fitted adaptive equipment. Additionally, there may be reluctance to prescribe occupational therapy or physical therapy based on costs. • Advocate for older adults to ensure that inactivity is not based Health care providers may be reluctant to ensure early mobilization on ageist perspectives. in older patients, especially the old-old clientele. • In the event of impaired cognitive function, remind the patient Prompting may encourage increased activity and decreased risk of need for and assist the patient (or caregiver) in mobilizing for disuse. efforts. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of causes, Provides for early recognition and intervention for problem. signs, and symptoms of Risk for Disuse Syndrome: � Prolonged bedrest � Circulatory or respiratory problems � New activity � Fatigue � Dyspnea � Pain � Vital signs (before and after activity) � Malnutrition � Previous inactivity � Weakness � Confusion � Fracture � Paralysis • Assist the client and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Progressive exercise to increase endurance � ROM and flexibility exercise � Treatments for underlying conditions (cardiac, respiratory, musculoskeletal, circulatory, neurologic, etc.) � Motivation � Assistive devices as required (walkers, canes, crutches, wheelchairs, ramps, wheelchair access, etc.) � Adequate nutrition � Adequate fluids � Stress management � Pain relief � Prevention of hazards of immobility (e.g., antiembolism stockings, ROM exercises, position changes) � Changes in occupations, family, or social roles � Changes in living conditions � Economic concerns � Proper transfer techniques � Bowel and bladder regulation • Teach the client and family purposes and side effects of Locus of control shifts from nurse to the client and family, thus medications and proper administration techniques (e.g., promoting self-care. anticoagulants or analgesics). • Assist the client and family to set criteria to help them determine when calling a physician or other interventions are required. • Consult with or refer to appropriate resources as indicated. Provides additional support for the client and family, and uses already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company 274 ACTIVITY-EXERCISE PATTERN Disuse Syndrome, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Repeat initial assessment. Does the client exhibit any signs or symptoms of disuse syndrome? Yes No Record data, e.g., actively performs ROM, lungs clear to auscultation. Record RESOLVED (may wish to use CONTINUE until your patient is discharged from your service). If Is diagnosis validated? RESOLVED, delete nursing diagnosis, expected outcome, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., has difficulty in performing full range of motion, faint rales heard in left lower lobe. Yes No Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company DIVERSIONAL ACTIVITY, DEFICIENT 275 Diversional Activity, Deficient DEFINING CHARACTERISTICS21 DEFINITION 1. Usual hobbies cannot be undertaken in hospital. 2. Patient’s statements regarding boredom (wish there was some- The state in which an individual experiences a decreased stimula- thing to do, to read, etc.). tion from or interest or engagement in recreational or leisure activ- ities.21 RELATED FACTORS21 NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 1. Environmental lack of diversional activity, as in: CLASS 2—ACTIVITY/EXERCISE a. Long-term hospitalization b. Frequent lengthy treatments NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING ASSISTANCE RELATED CLINICAL CONCERNS NOC: DOMAIN IV—HEALTH KNOWLEDGE AND BEHAVIOR; CLASS Q—HEALTH BEHAVIOR Any medical diagnosis that could be connected to the related factors. HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Activity Intolerance If the nurse observes or Social Isolation This diagnosis should be validates reports of the patient’s inability to considered if the patient demonstrates limited complete required tasks because of insufficient contact with community, peers, and significant energy, then Activity Intolerance is the appropriate others. When the patient talks of loneliness rather diagnosis, not Deficient Diversional Activity. than boredom, Social Isolation is the most Impaired Physical Mobility When the patient has appropriate diagnosis. difficulty with coordination, range of motion, or Disturbed Sensory Perception This diagnosis muscle strength and control or has activity would be the best diagnosis if the patient is unable restrictions related to treatment, the most to engage in his or her usual leisure time activities appropriate diagnosis is Impaired Physical Mobility. as a result of loss or impairment of one of the Deficient Diversional Activity is quite likely to be a senses. companion diagnosis to Impaired Physical Mobility. EXPECTED OUTCOME TARGET DATES Will assist in designing and implementing a plan to overcome de- Planning and accessing resources will require a moderate amount ficient diversional activity by [date]. of time. A reasonable target date would be within 2 to 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • On admission, assist the patient to review activity likes and Finds the activities the patient would most likely engage in. dislikes. • When this diagnosis is made, move the patient to semiprivate Provides companionship, social interaction, and diversion. room if possible and if the patient is amenable to move. • Encourage the patient to discuss feelings regarding deficit and Helps the patient identify feelings and begin to deal with them. causes at least once per day at [time]. • Involve the patient, to extent possible, in more daily self-care Increases self-worth and adequacy. activities. • Alter daily routine (e.g., bathe at different times or increase Creates change and provides some diversion. ambulation). • Rearrange environment as needed: Facilitates activity. � Provide ample light. � Place bed near window. (continued) Copyright © 2002 F.A. Davis Company 276 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS

RATIONALES � Provide radio as well as television set. � Place books, games, etc. within easy reach. � Provide clear pathway for wheelchair, ambulations, etc. � Move furniture. • Provide change of environment at least twice a day at [times], Creates change and broadens range of activities. e.g., out of room to sun deck or outside building. Add posters to room decor. • Encourage significant others to assist in increasing diversional Reinforces “normal” lifestyle, and encourages feelings of self-worth. activity: � Bringing books, games, or hobby materials � Visiting more frequently � Encouraging other visitors � Bringing a box of wrapped small items, one to be opened each day, e.g., paperback book, crossword puzzles, small jigsaw puzzle, or small handheld games • Provide for appropriate adaptations in equipment or positioning to facilitate desired diversional activity. • Provide for scheduling of diversional activity at a time when the patient is rested and without multiple interruptions. • Refer the patient to individual health care practitioners who can best assist with problem. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the patient’s potential for activity or diversion Provides essential database for planning desired and achievable according to: diversion. � Attention span � Physical limitations and tolerance � Cognitive, sensory, and perceptual deficits � Preferences for gender, age, and interests � Available resources � Safety needs � Pain • Encourage parental input in planning and implementing desired Helps ensure that plan is attentive to the child’s interests, thus diversional activity plan. increasing the likelihood of the child’s participation. • Allow for peer interaction when appropriate through diversional Involvement of peers serves to foster self-esteem and meets activity. developmental socialization needs. Women’s Health NOTE: The following refers to those women placed on restrictive activities because of threatened abor- tions, premature labor, multiple pregnancy, or pregnancy-induced hypertension. ACTIONS/INTERVENTIONS RATIONALES • Encourage the family and significant others to participate in Promotes socialization, empowers the family, and provides plan of care for the patient. opportunities for teaching. • Encourage the patient to list lifestyle adjustments that need to be Basic problem-solving technique that encourages the patient to made as well as ways to accomplish these adjustments. participate in care. Will increase understanding of current condition. • Teach the patient relaxation skills and coping mechanisms. • Maintain proper body alignment with use of positioning and pillows. • Provide diversional activities: Provides a variety of options to offset deficit. � Hobbies, e.g., needlework, reading, painting, or television � Job-related activities as tolerated (that can be done in bed), e.g., reading, writing, or telephone conferences (continued) Copyright © 2002 F.A. Davis Company DIVERSIONAL ACTIVITY, DEFICIENT 277 (continued) ACTIONS/INTERVENTIONS RATIONALES � Activities with children, e.g., reading to the child, painting or coloring with child, allowing child to “help” mother (bringing water to mother or assisting in fixing meals for mother) � Encourage help and visits from friends and relatives, e.g., visit in person, telephone visit, help with childcare, or help with housework Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Assess source of deficient diversional activity. Is the nursing unit Recognizes the impact of physical space on the client’s mood. appropriately stimulating for the level or type of clients, or is the problem the client’s perceptions? NURSING UNIT–RELATED PROBLEMS • Develop milieu therapy program: Promotes here-and-now orientation and interpersonal interactions. � Include seasonal activities for clients, such as parties, special meals, outings, or games. � Alter unit environment by changing pictures, adding Enhances the aesthetics of the environment and has a positive effect appropriate seasonal decorations, updating bulletin boards, on the client’s mood.33 cleaning and updating furniture. � Alter mood of unit with bright colors, seasonal flowers, or Colors and sounds affect the client’s mood.33 appropriate music. � Develop group activities for clients, such as team sports, Provides opportunities to build social skills and alternative Ping-Pong, bingo games, activity planning groups, meal methods of coping. planning groups, meal preparation groups, current events discussion groups, book discussion groups, exercise groups, or craft groups. � Decrease emphasis on television as primary unit activity. Television does not provide opportunities for learning alternative coping skills and decreases physical activity. � Provide books, newspapers, records, tapes, and craft materials. These resources assist the client in meeting belonging needs by facilitating interaction with others on the unit and the world around him or her. � Use community service organizations to provide programs Provides varied sensory stimulation. for clients. • Collaborate with occupational therapist for ideas regarding activities and supplies. • Collaborate with physical therapist regarding physical exercise program. CLIENT PERCEPTION–RELATED PROBLEMS • Discuss with the client past activities, reviewing those that have Promotes the client’s sense of control. been enjoyed and those that have been tried and not enjoyed. • List those activities that the client has enjoyed in the past, with information about what keeps the client from doing them at this time. • Monitor the client’s energy level, and develop activity that Promotes development of alternative coping behaviors by assisting corresponds to the client’s energy level and physiologic needs. the client in choosing appropriate activities. For example, a manic client may be bored with playing cards and yet physiologic needs require less physical activity than the client may desire, so an appropriate activity would address both these needs. Note assessment decision here. • Develop with the client a plan for reinitiating a previously Promotes the client’s sense of control enjoyed activity. Note that plan here. . • Develop time in the daily schedule for that activity, and note that time here. • Relate activity to enjoyable time, such as a time for interaction Interaction can provide positive reinforcement for engaging in with the nurse alone or interaction with other clients in a group activity. area. • Provide positive verbal feedback to the client about his or her Positive verbal reinforcement encourages appropriate coping efforts at the activity. behaviors. (continued) Copyright © 2002 F.A. Davis Company 278 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client in obtaining necessary items to implement Facilitates appropriate coping behaviors. activity, and list necessary items here. • Develop plan with the client to attempt one new activity—one Promotes the client’s perceived control, and provides positive that has been interesting for him or her but that he or she has reinforcement for the behavior. not had time or direction to pursue. Note plan and rewards for accomplishing goals here. • Have the client set realistic goals for activity involvement (e.g., Promotes the client’s strengths and self-esteem. one cannot paint like a professional in the beginning). • Discuss feelings of frustration, anger, and discomfort that may Verbalization of feelings and thoughts provides opportunities for occur as the client attempts a new activity. developing alternative coping strategies. • Frame mistakes as positive tools of learning new behavior. Promotes the client’s strengths. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Ask the patient if activities were decreased prior to hospitalization. If decreased activities were noted prior to admission, there may be ongoing problems that are not related to the acute care setting. • Provide at least 10–15 min per shift, while awake, to engage in Increases self-esteem, and focuses on strengths the patient has reminiscing with the patient. developed over his or her lifetime.68 Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor factors contributing to deficient diversional activity. Provides database for prevention and/or early intervention. • Involve the client and family in planning, implementing, and Involvement improves motivation and improves the outcome. promoting increase in diversional activity: � Family conference � Mutual goal setting � Communication • Assist the client and family in lifestyle adjustments that may be Provides basic information for the client and family that promotes required: necessary lifestyle changes. � Time management � Work, family, social, and personal goals and priorities � Rehabilitation � Learning new skills or games � Development of support systems � Stress management techniques � Drug and alcohol use • Refer the patient to appropriate assistive resources as indicated. Provides additional support for the client and family, and uses already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company DIVERSIONAL ACTIVITY, DEFICIENT 279 Diversional Activity, Deficient FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient have a plan, verbal or written, designed to overcome deficient diversional activity? Yes No Has the patient implemented the plan? No Reassess using initial assessment factors. Yes Record data, e.g., has had family bring in hobby materials, has two new novels, No Is diagnosis validated? has checkers tournament going with roommate. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., states doesn’t like games or reading; doesn’t Did evaluation show another have any hobbies. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 280 ACTIVITY-EXERCISE PATTERN Dysfunctional Ventilatory Weaning d. Ineffective airway clearance 2. Psychological Response (DVWR) a. Patient-perceived inefficacy about the ability to wean b. Powerlessness DEFINITION c. Anxiety (moderate or severe) A state in which a patient cannot adjust to lowered levels of me- d. Knowledge deficit of the weaning process and patient role chanical ventilator support, which interrupts and prolongs the e. Hopelessness weaning response.21 f. Fear g. Decreased motivation h. Decreased self-esteem NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; i. Insufficient trust of the nurse CLASS 4—CARDIOVASCULAR/PULMONARY 3. Situational RESPONSE a. Uncontrolled episodic energy demands or problems NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; b. Adverse environment (noisy, active environment, negative CLASS K—RESPIRATORY MANAGEMENT events in the room, low nurse-patient ratio, extended nurse absence from bedside, or unfamiliar nursing staff ) NOC: DOMAIN II—PHYSIOLOGIC HEALTH; c. History of multiple unsuccessful weaning attempts CLASS E—CARDIOPULMONARY d. History of ventilator dependence 1 week e. Inappropriate pacing of diminished ventilator support DEFINING CHARACTERISTICS21 f. Inadequate social support 1. Mild DVWR RELATED CLINICAL CONCERNS a. Warmth b. Restlessness 1. Closed head injury c. Slight increased respiratory rate from baseline 2. Coronary bypass d. Queries about possible machine malfunction 3. Respiratory arrest e. Expressed feelings of increased need for oxygen 4. Cardiac arrest f. Fatigue 5. Cardiac transplant g. Increased concentration on breathing h. Breathing discomfort 2. Moderate DVWR a. Slight increase from baseline blood pressure 20 mm Hg b. Baseline increase in respiratory rate 5 breaths per minute HAVE YOU SELECTED c. Slight increase from baseline heart rate 20 beats per minute THE CORRECT DIAGNOSIS? d. Pale, slight cyanosis e. Slight respiratory accessory muscle use Ineffective Breathing Pattern In this f. Inability to respond to coaching diagnosis, the patient’s respiratory effort is g. Inability to cooperate insufficient to maintain the cellular oxygen h. Apprehension supply. This diagnosis would contribute to i. Color changes the patient’s being placed on ventilatory j. Decreased air entry on auscultation assistance; however, DVWR occurs after the k. Diaphoresis patient has been placed on a ventilator and l. Eye widening, “wide-eyed look” efforts are being made to reestablish a m. Hypervigilence to activities regular respiratory pattern. The key 3. Severe DVWR difference is whether or not a ventilator has a. Deterioration in arterial blood gases from current baseline been involved in the patient’s therapy. b. Respiratory rate increases significantly from baseline Impaired Gas Exchange This diagnosis c. Increase from baseline blood pressure 20 mm Hg refers to the exchange of oxygen and carbon d. Agitation dioxide in the lungs or at the cellular level. e. Increase from baseline heart rate 20 beats per minute This probably has been a problem for the f. Paradoxical abdominal breathing patient and is one of the reasons the patient g. Adventitious breath sounds was placed on a ventilator. DVWR would h. Cyanosis develop after the patient has received i. Decreased level of consciousness treatment for the impaired gas exchange via j. Full respiratory accessory muscle use the use of a ventilator. k. Shallow, gasping breaths l. Profuse diaphoresis m. Discoordinated breathing with the ventilator EXPECTED OUTCOME n. Audible airway secretion Will be weaned from the ventilator by [date]. RELATED FACTORS21 TARGET DATES 1. Physiologic a. Inadequate nutrition Initial target dates should be in terms of hours as the patient is go- b. Sleep pattern disturbance ing through the weaning process. As the patient improves, the tar- c. Uncontrolled pain or discomfort get date could be expressed in increasing intervals from 1 to

3 days. Copyright © 2002 F.A. Davis Company DYSFUNCTIONAL VENTILATORY WEANING RESPONSE (DVWR) 281 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Coach the patient to take maximum inspiration and then exhale Encourages the patient to initiate respiration. all the air that he or she can. Check vital capacity measures (should be at least 10 mL/kg). • Measure inspiratory force with pressure manometer (the force Measures respiratory muscle strength. needed to optimize successful weaning is 20 to 30). • Assess PaO2 (should be 60 or more at 40 percent oxygen) and Indicates amount of oxygen in alveoli. O2 saturation (with pulse oximeter—should be equal to or more than 94). • Determine positive end-expiratory pressure (PEEP). Physiologic PEEP should be sufficient to prevent collapse of alveoli. PEEP is generally 5 cm H2O. • Assess tidal volume. Should be at least 3 mL/kg. Essential for maintenance of adequate ventilation. • Assess vital signs and respiratory pattern during weaning. Essential monitoring of changes in respiratory effort and oxygenation. • Use weaning technique ordered by physician (T-Piece or intermittent mandatory ventilation [IMV] technique). • Plan goals for weaning, and explain weaning procedure. Start Ensures continuous monitoring of weaning success. Enables nurse weaning process at scheduled time off ventilator. Stay with the to place the patient back on ventilator as soon as necessary. patient during weaning process. Stop weaning process before the patient becomes exhausted. • Reassure the patient that you are there in case of problems and Instills trust, decreases anxiety, and increases motivation. that he or she can breathe on his or her own. • If unable to wean while the patient is still in the hospital, assess Coordinates team efforts and allows sufficient planning time for resources and support systems at home. Refer to home health or home care. public health department at least 3 days prior to discharge. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all contributing factors as applicable.69 Provides a database that will assist in generating the most � Pathophysiologic health concerns, e.g., infections, anemia, individualized plan of care. fever, or pain � Previous respiratory history, especially risk indicators of reactive airway disease and bronchopulmonary dysplasia � Previous cardiovascular history, especially risk indicators such as increased or decreased pulmonary blood flow associated with congenital deficits � Previous neurologic status � Recent surgical procedures � Current medication regimen � Psychological and emotional stability of the parents as well as the child • Determine respirator parameters that suggest readiness to Specific ventilator-related criteria offer the best decision-making begin weaning process.70 Collaborate with physician, respiratory support for determining the best plan of ventilator weaning. therapist, and other health care team members: � Spontaneous respirations for age, e.g., rate or depth � Oxygen saturations in normal range for condition, e.g., spontaneous tidal volume of 5 mL/kg body weight, vital capacity per Wright Respirometer of 10 mL/kg body weight, effective oxygenation with PEEP of 4–6 cm H2O. An exception to the norms would exist if the infant has transposition of the great vessels. � Blood gases in normal range (continued) Copyright © 2002 F.A. Davis Company 282 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Stable vital signs � Parental or patient anxiety regarding respirator � Patient’s facial expression and ability to rest � Resolution of the precipitating cause for intubation and mechanical support � Tolerance of suctioning and use of Ambu bag � Central nervous system and cardiovascular stability � Nutritional status, muscle strength, pain, drug-induced respiratory expression, or sleep deprivation NOTE: Oxygen saturation, blood gases, and vital signs may be abnormal secondary to chronic lung damage with accompanying hypoxemia and hypercapnia, but the pH may be normal with metabolic compensation for chronic respiratory acidosis. In this instance, acceptable ranges would be defined. • Provide constant one-to-one attention to the patient, and focus Hierarchy of needs for oxygenation must be met for all vital primarily on cardiorespiratory needs. Have CPR backup functions to be effective in homeostasis. Anticipatory safety for a equipment readily available. patient on a ventilator demands backup equipment in case of failure of the current equipment. • Monitor the anxiety levels of the patient and family at least once Expression of feelings will assist in monitoring family concerns per shift. and help reduce anxiety. • Monitor patient-specific parameters during actual attempts at Assists in further planning for weaning. weaning: � Arterial blood gases � Vital signs � Chest sounds � Pulse oximetry � Chest x-ray � Hematocrit • Provide teaching as appropriate for the patient and family, with Assessment and individualized learning needs allow appropriate emphasis on the often slow pace of weaning. focus on the patient. Explanation regarding the slow pace encourages a feeling of success rather than failure when each session does not meet the same time limits as the previous session. • Provide attention to the rising of related emotional problems With the need to implement intubation and ventilation, there can secondary to the association of ventilators with terminal arise a myriad of concerns regarding the patient’s prognosis. life-support. • Refer the patient for long-term follow-up as needed. Fosters long-term support and coping with care at home. • Administer medications as ordered with appropriate attention The best chance for successful weaning includes appropriate to preparation for weaning, e.g., careful use of paralytic agents consciousness, no respiratory depression, and adequate or narcotics. neuromuscular strength. Special caution must be taken in positioning the patient receiving neuromuscular blocking agents so that dislocation of joints does not occur.71 • Maintain a neutral thermal environment. Altered oxygenation and metabolic needs occur in instances of hyperthermia and hypothermia. • Provide the parents the option to participate in care as permitted. Family input offers emotional input and security for the child in times of great stress, thereby allowing for growth in parental-child coping behaviors. • Communicate with the infant or child using age-appropriate Effective communication serves to allow for expression of or methods, e.g., an infant will enjoy soft music or a familiar voice, reception of messages of cares or concerns, thereby acknowledging whereas an older child may be able to use a small magic slate or value of the patient. point to key terms. Women’s Health The nursing actions for Women’s Health clients with this diagnosis are the same as those for Adult Health. Psychiatric Health This diagnosis is not appropriate for the mental health care unit. Copyright © 2002 F.A. Davis Company DYSFUNCTIONAL VENTILATORY WEANING RESPONSE (DVWR) 283 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the patient for presence of factors that make weaning These factors can significantly contribute to a delay in the weaning difficult, such as72: process. � Poor nutritional status � Infection � Sleep disturbances � Pain � Poor positioning � Large amounts of secretions � Bowel problems • Ensure that communication efforts are enhanced by the proper Effective communication is critical to success of weaning efforts. use of sensory aids such as eyeglasses, hearing aids, or adequate Lack of information or misinterpreted information may result in light, and decrease the noise level in room, speaking in a increased anxiety and decreased weaning success. low-pitched tone of voice and facing the patient when speaking. If written instructions are used, make sure they are brief, jargon-free, printed or written in dark ink, and printed or written in large letters. • Maintain same staff assignments whenever possible.73 Facilitates communication, and decreases anxiety and fear caused by unfamiliarity with caregivers. • Contract with the patient for short-term and long-term weaning goals, providing reinforcements and rewards for progress. Use wall chart or diary to record progress. Home Health Clients are discharged to the home health setting with ventilators; however, the nursing care required is the same as those actions covered in Adult Health and Gerontic Health. Copyright © 2002 F.A. Davis Company 284 ACTIVITY-EXERCISE PATTERN Dysfunctional Ventilatory Weaning Response (DVWR) FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient completely weaned from ventilator? Yes No Record data, e.g., has not required Reassess using initial assessment factors. ventilator for 3 days; vital signs and blood gases have remained within normal limits (see vital sign flow sheet and lab reports). Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., cannot remain off of ventilator for more than 15 min Did evaluation show another without dyspnea, vital sign changes, problem had arisen? Yes and cyanosis. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company FALLS, RISK FOR 285 Falls, Risk for (7) Hypnotics or tranquilizers (8) Narcotics DEFINITION e. Environment (1) Restraints Increased susceptibility to falling that may cause physical harm.21 (2) Weather conditions (e.g., wet floors or ice) (3) Throw or scatter rugs NANDA TAXONOMY: DOMAIN 11—SAFETY/ (4) Cluttered environment PROTECTION; CLASS 2—PHYSICAL INJURY (5) Unfamiliar, dimly lit rooms (6) No antislip material in bath and/or shower NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 2. Children CLASS A—ACTIVITY AND EXERCISE MANAGEMENT a. Younger than 2 years of age NOC: DOMAIN I—FUNCTIONAL HEALTH; b. Male gender when younger than 1 year of age CLASS C—MOBILITY c. Lack of autorestraints d. Lack of gate on stairs e. Lack of window guard DEFINING CHARACTERISTICS21 f. Bed located near window g. Unattended infant on bed, changing table, or sofa 1. Adults h. Lack of parental supervision a. Demographics (1) History of falls (2) Wheelchair use RELATED FACTORS21 (3) Age 65 or older The risk factors also serve as related factors. (4) Female (if elderly) (5) Lives alone (6) Lower limb prosthesis RELATED CLINICAL CONCERNS (7) Use of assistive devices 1. Vertigo b. Physiologic 2. Osteoporosis (1) Presence of acute illness 3. Hypotension (2) Postoperative conditions 4. Recent history of anesthesia (3) Visual difficulties 5. Cataracts or glaucoma (4) Hearing difficulties 6. Cerebrovascular insufficiency (5) Arthritis 7. Epilepsy (6) Orthostatic hypotension (7) Sleeplessness (8) Faintness when turning or extending neck (9) Anemias HAVE YOU SELECTED (10) Vascular disease THE CORRECT DIAGNOSIS? (11) Neoplasms (i.e., fatigue or limited mobility) (12) Urgency and/or incontinence Risk for Injury This diagnosis is a broader (13) Diarrhea diagnosis than Risk for Falls. Certainly, a fall (14) Decreased lower extremity strength would increase the likelihood of injury, but (15) Postprandial blood sugar changes making the specific diagnosis of Risk for (16) Foot problems Falls as a primary problem allows more (17) Impaired physical mobility specific focus on prevention. (18) Impaired balance Impaired Physical Mobility This diagnosis is (19) Difficulty with gait a contributing factor to falls. Again, Risk for (20) Unilateral neglect Falls would be a more specific diagnosis. (21) Proprioceptive deficits (22) Neuropathy c. Cognitive (1) Diminished mental status (e.g., confusion, delirium, EXPECTED OUTCOME dementia, impaired reality testing) d. Medications Will have experienced no falls by [date]. (1) Antihypertensive agents (2) Angiotensin-converting enzyme (ACE) inhibitors TARGET DATES (3) Diuretics (4) Tricyclic antidepressants A patient with this diagnosis would need to be checked at least (5) Alcohol use hourly. After some of the risk factors have been alleviated, an ap- (6) Antianxiety agents propriate target date would be 5 days. Copyright © 2002 F.A. Davis Company 286 ACTIVITY-EXERCISE PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Keep the bed in a low position or just have the mattress on the Lessens the distance of a fall. floor. • Provide time for low-impact or moderate exercise. Helps maintain muscle strength, balance, endurance, and gait. • Assess environment and remove hazards. Safety and security. • Provide assistance, when needed, in ambulation activities; Safety and security. consider protective hip pads and gait devices. • Provide slip-resistant surfaces in the bathroom tub or shower; Safety and security. raise toilet seats. • Ensure that there are grab bars in bathroom or in room; ensure Safety and security. that handrails are installed in halls. • Assess medications, both prescription and over-the-counter. May have adverse effects or interactions. • Keep frequently used items at shoulder to knee level. Avoids reaching and becoming off balance.74 • Involve the patient in identifying ways to prevent falls. Empowers the patient to take an active role in own health care. • Use protective alarm sensors as necessary. Identifies when the patient is outside safety limits.74 • Use alternatives to physical or chemical restraints. Lessens independence and

may lead to more falls.75 • Educate the family on fall prevention strategies. Empowers the family to become a part of caregiving. • Refer to the Gerontic and Home Health Nursing Care Plans. Child Health ACTIONS/INTERVENTIONS RATIONALES • Identify all contributing factors, including: A holistic approach provides a thorough database to provide � Neurologic individualized care. � Musculoskeletal � Cardiovascular � Cognitive � Developmental � Environmental � Situational � Pharmacologic � Medical • Ensure safety in environment on an ongoing basis. Risk is reduced by anticipatory safety measures. • Provide teaching to the client, family, and health team members Standardization and shared plan will afford best chance for based on specific content per plan. attainment of goal with empowerment of others to provide appropriate assistance. • Provide transfer of principles of prevention to alternate settings Offers validation of the importance of principles of safety that can as required per daily activities of living, e.g., playroom, dining be applied in future as needed. area, etc. • Maintain ongoing surveillance for potential changes. Constant anticipatory safety needs are mandatory. • Determine the need for posthospitalization teaching regarding Provides appropriate time for questions or concerns prior to preventive or related data. dismissal. • Administer medications, treatments, or related care in a manner Clustering of care and appropriate attention to timing of that permits best likelihood for noninterference in usual mobility. medications or treatments will best afford safety and lessen risk. • Ensure adequate lighting on a 24-h basis. Safety needs include appropriate lighting, especially at night or in times of darkness. • Ensure availability of assistive devices as required per client, e.g., Appropriate augmentation as needed will prevent likelihood of falls. corrective lenses, braces, helmet, etc. Women’s Health The nursing interventions for this diagnosis in Women’s Health are the same as those for Adult Health and Gerontic Health. Copyright © 2002 F.A. Davis Company FALLS, RISK FOR 287 Psychiatric Health The nursing interventions for this diagnosis in Psychiatric Health are the same as those for Adult Health and Gerontic Health. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Perform fall risk assessment on all older clients, appropriate to Risk factors for falls in older clients are multifactorial, and the caregiving site. site-specific assessment tools help target factors (such as equipment, structures, furnishings, personnel issues) that may increase fall potential. • Ensure that any sensory adaptive equipment is available and Visual and auditory deficits can affect balance.13 properly functioning. • Consult with occupational therapist and phhysical therapist for The factors listed have been identified as having an impact on the balance, gait, transfer, and strength assessment and training as potential for falls in older adults.18 needed. • Review drug list to evaluate any medication-associated risks, These medications have been shown to increase the incidence of such as diuretics, antihypertensives, sedatives, psychotropics, falls in older adults.76 and hypoglycemic drugs. • Develop teaching plan for the client and/or caregiver to reduce Raises awareness of fall potential and strategies needed to reduce fall potential based on risk factors present. risks. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assess the home for hazards: Basic safety measures. � Throw rugs � Electrical cords � Uneven floor surfaces � Raised thresholds � Slick floors � Animals • Modify the home to reduce or eliminate hazards: The items listed are primary hazards. � Skidproof surfaces in showers, on stairs � Mark uneven areas and stairs � Eliminate throw rugs and cords � Safety rails in halls, stairs, bathrooms • Assess client-related factors that increase risk for falls: Basic safety measures. � Poorly fitting shoes � Medications that increase sedation or contribute to dizziness � History of falls � Inner ear infections or disorders • Educate the client and family about reducing client-related factors that increase risk for falls: � Medication effects or side effects � Changing position slowly to reduce risk � Acquire properly fitting, nonskid footwear • Utilize night lights in dark areas. • Reduce or eliminate clutter in traffic areas. • Refer the client and family to an emergency response service as To provide rapid response should a fall occur. appropriate. • Utilize gates to keep pets isolated if they pose a risk for falls. • Request a physical therapy consult as appropriate to improve muscle strength and gait. • Request a physical therapy consult to ensure the correct use of To prevent injury before it occurs. assistive devices. Copyright © 2002 F.A. Davis Company 288 ACTIVITY-EXERCISE PATTERN Falls, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient fallen? Yes No Reassess using initial assessment factors. Record data, e.g., has not fallen during past 5 days. States having no problems with walking. Record RESOLVED (may wish to use CONTINUE until the patient is discharged from your service). Is diagnosis validated? Delete nursing diagnosis, expected outcomes, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., has fallen twice over past 5 days. States still gets dizzy. Record CONTINUE Yes No and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company FATIGUE 289 Fatigue 4. Physiologic a. Sleep deprivation DEFINITION b. Pregnancy c. Poor physical condition An overwhelming sustained sense of exhaustion and decreased d. Disease states capacity for physical and mental work.21 e. Increased physical exertion f. Malnutrition NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; g. Anemia CLASS 3—ENERGY BALANCE NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; RELATED CLINICAL CONCERNS CLASS A—ACTIVITY AND EXERCISE MANAGEMENT 1. Acquired immunodeficiency syndrome (AIDS) NOC: DOMAIN I—FUNCTIONAL HEALTH; 2. Hyper- or hypothyroidism CLASS A—ENERGY MAINTENANCE 3. Cancer 4. Menopause 5. Depression DEFINING CHARACTERISTICS21 6. Anemia 1. Inability to restore energy even after sleep 2. Lack of energy or inability to maintain usual level of physical activity HAVE YOU SELECTED 3. Increase in rest requirements THE CORRECT DIAGNOSIS? 4. Tired 5. Inability to maintain usual routines Disturbed Sleep Pattern Fatigue is defined 6. Verbalization of an unremitting and overwhelming lack of as a sense of exhaustion and decreased energy capacity for mental work regardless of 7. Lethargic or listless adequate sleep. In this sense, Fatigue may be 8. Perceived need for additional energy to accomplish routine tasks considered an alteration in quality, not 9. Increase in physical complaints quantity, of sleep and is subjective. 10. Compromised concentration Decreased Cardiac Output Decreased 11. Disinterest in surroundings, introspection oxygenation to the muscles, brain, and so 12. Decreased performance on could result in a sense of fatigue. 13. Compromised libido 14. Drowsy Imbalanced Nutrition, Less Than Body 15. Feelings of guilt for not keeping up with responsibilities Requirements Decreased nutrition will ultimately lead to decreased muscle mass and decreased energy, which will result in RELATED FACTORS21 Fatigue. 1. Psychological a. Boring lifestyle b. Stress EXPECTED OUTCOME c. Anxiety d. Depression Will have decreased complaints of fatigue by [date]. 2. Environmental a. Humidity TARGET DATES b. Lights c. Noise Fatigue can have far-reaching impact. For this reason, the initial tar- d. Temperature get date should be set at no more than 4 days. 3. Situational a. Negative life events b. Occupation NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with diet therapist for in-depth dietary assessment Adequate, balanced nutrition assists in reducing fatigue. and planning. Monitor the patient’s food and fluid intake daily. • Monitor for contributory factors on a daily basis at [time]. Assists in identifying causative factors, which then can be treated. (continued) Copyright © 2002 F.A. Davis Company 290 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Carefully plan activities of daily living (ADLs) and daily exercise Realistic schedules based on the patient’s input promote schedules with detailed input from the patient. Determine how participation in activities and a sense of success. to best foster future patterns that will maintain optimal sleep-rest patterns without fatigue through planning ADLs with the patient and family. • Assign staff on a consistent basis. Promotes adherence to planned schedule, and facilitates the patient’s understanding of the need to be consistent in plan. • Provide frequent rest periods. Schedule at least 30 min rest after Allows the patient to gradually increase strength and tolerance for any strenuous activity. activities. • Assist the patient with self-care as needed. Plan gradual increase in activities over several days. • Provide adequate input about usual sleep pattern versus current Increases quantity and quality of rest and sleep. pattern associated with fatigue. • Promote rest at night: � Warm bath at bedtime � Warm milk at bedtime � Back massage • Avoid sensory overload or sensory deprivation. Provide Sensory aspects can deplete energy stores; diversional activities diversional activities. help prevent overload or deprivation by focusing the patient’s concentration on an activity he or she personally enjoys. • Instruct the patient in stress reduction techniques. Have the Mental and physical stress greatly contribute to sense of fatigue. patient return-demonstrate at least once a day through day of discharge. • Assist the patient to realistically appraise personal short- and Feeling overwhelmed by too many or unrealistic goals can increase long-term goals. fatigue. • Collaborate with physician regarding medical status and Several medical diagnoses include fatigue as a symptom that can be condition and its impact on promoting chronic fatigue. offset by careful planning of care. • Assist the patient to schedule at least 1 recreational night per Provides distraction from overfocus on work or other such week and 1 rest evening per week. Have the patient sign demands. Assists in reducing stress, which contributes to fatigue. contract with significant other to promote compliance with this schedule. • Refer to local exercise center for assistance with regular exercise Regular exercise decreases fatigue. plan. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine a plan to best address contributory factors as Parents are best able to describe objective behaviors that offer cues determined by verbalized perceptions of fatigue (may be to fatigue factors, especially when the patient cannot speak or related to parents’ perceptions). describe his or her feelings. • Provide daily feedback regarding progress, and reassess the Because of the ever-changing fatigue factors, close attention to child’s and the family’s perception of fatigue. progress will aid in a sense of mastery and objectify concerns. • Ensure safety needs according to the child’s or infant’s age and Standard accountability is to provide for safety needs with special developmental capacity. attention to the child’s age, developmental capacity, parental education, compliance, etc. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • During pregnancy, schedule rest periods during day. Realistic planning to offer brief rest periods during the day. • Find restful area, one time in the morning and one time in the afternoon, to get away from work area and rest 5–10 min with feet propped above the abdomen. • During lunch, leave work area to rest 10–15 min lying on left side or with feet propped above the abdomen. • Have the patient research the possibility of split time or job sharing at work during pregnancy. (continued) Copyright © 2002 F.A. Davis Company FATIGUE 291 (continued) ACTIONS/INTERVENTIONS RATIONALES • Teach the patient relaxation techniques. Techniques induce a restful state and can be used for short periods of rest as well as more extended periods of rest. • Teach the patient to use music of preference during rest periods. Assists with relaxation. • Plan for at least 6–8 h of sleep during night. (See Disturbed Sleep Pattern, Chap. 6, for nursing actions to promote sleep.) • Involve significant others in discussion and problem-solving The family can assume more responsibilities to assist in increasing activities regarding lifestyle changes needed to reduce fatigue. rest time for the patient. • After delivery, identify a support system that can assist the Assists in alleviating fatigue related to trying to manage household patient with infant care and household duties. as always as well as trying to care for a new baby. • Learn to rest and sleep when the infant sleeps. Conserves energy and increases amount of time available for rest. • Plan daily activities to alleviate unnecessary steps and to allow for frequent rest periods. � If bottle-feeding, prepare formula for 24 h at a time. � If breastfeeding, let spouse get up at night and bring the baby to the mother. � If breastfeeding, sleep with the baby in bed. Baby begins to

feed for longer periods and begins to sleep longer � Prepare extra when cooking meals for the family, and more quickly. Both the mother and infant get more rest. freeze extra for future meals (e.g., prepare big batch of stew or spaghetti on one day and freeze portions for future meals). • Plan return to work on a gradual basis (e.g., work part-time for Provides gradual return to activities, and decreases likelihood of the first 2 wk, gradually increasing time at work until full-time fatigue. by end of 4 wk). Psychiatric Health NOTE: All goals established for the nursing actions should be achievable and adjusted as the client’s condition changes. ACTIONS/INTERVENTIONS RATIONALES • The client must be out of bed and dressed by [note time here]. Provides goal the client can achieve, and enhances self-esteem. Initially this goal may be limited to the client getting out of bed without dressing. • Assist the client with grooming activities (note here the degree Promotes the client’s sense of control, and enhances self-esteem. of assistance needed as well as any special items needed). • While assisting the client with grooming activities, teach Promotes the client’s control by providing increased opportunity performance of tasks in energy-efficient ways, e.g., placing all for self-care. necessary items in one place before grooming is begun. • Provide the client with appropriate rewards for accomplishing Positive reinforcement encourages appropriate behavior. established goals (note special goals here with the reward for achievement of goal). Establish rewards with client input. • Establish time for the client to rest during the day. Initially this Meets physiologic need for rest. Also provides the client with an will be more frequent and diminish as the client’s condition opportunity for perceived control in determining when these rest changes. Note times and duration of rest periods here. periods should be provided. • Walk with the client on unit [number] minutes [number] times Promotes cardiorespiratory fitness, and promotes self-esteem by a day. providing a goal the client can meet. Interaction with the nurse can provide positive reinforcement for this activity. • Have the client identify pleasurable activities that cannot be Promotes positive orientation by connecting the client with images performed because of fatigue. of past pleasures, and provides material for developing positive imaging. • Identify one pleasurable activity, and develop a gradually Promotes positive orientation by providing the client with positive escalating plan for client involvement in this activity. Provide goal to work toward. This will increase motivation. Positive rewards for accomplishment of each step in this plan. reinforcement encourages behavior. • Provide the client with foods that are high in nutritional value Meets physiologic needs for nutrition in a manner that conserves and are easy to consume. energy. • Talk with the client 30 min twice a day. Topics for this Promotes the client’s sense of control by providing time for his or discussion should include: her input into plan of care on a daily basis; also provides positive � Client’s perception of the problem reinforcement through social interaction with the nurse and verbal � Identification of thoughts that support the feeling of fatigue feedback about accomplishments. � Identification of thoughts that decrease feelings of fatigue � Identification of unrealistic goals � Client’s evaluation of and attitudes toward self (continued) Copyright © 2002 F.A. Davis Company 292 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Identification of circumstances in the client’s environment that support continuing feelings of fatigue (e.g., family stressors or secondary gain from fatigue) � Identification of the client’s accomplishments • After the client has verbalized the effects negative thoughts have Cognitive maps impact feelings and behavior. When cognitive on feelings and behavior, teach the client how to stop negative maps are used inappropriately, they can promote maladaptive thoughts and replace them with positive thoughts. thinking, behaving, and feeling. Recognition of dysfunctional maps provides the client with the opportunity for developing positive orientation and adaptive cognitive maps.35 • Reward the client for positive self-statements. Positive reinforcement encourages appropriate behavior. • Assign the client tasks on the unit, and provide positive reinforcement for task accomplishment. Note task assigned and reward established here. • Involve the client in group activity with other clients for Interaction with peers provides opportunities to increase social [number] minutes [number] times a day. network, learn problem-solving strategies, and test perceptions of self and experiences with peers. • Meet with the client and client’s family to evaluate interaction Family support enhances probability of behavior changes being patterns and provide information that would assist them in maintained after discharge. assisting the client. • Have the client identify those factors that will maintain feeling Reinforces behavior change and new coping skills, while providing of well-being after discharge, and develop a specific behavioral positive feedback and enhancing self-esteem.35 plan for implementing them. Note plan here. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review medications for side effects or possible drug interactions. Many medications can contribute to the sensation of fatigue. • Collaborate with physician regarding assessing the patient for Depression is often underreported and undertreated in older adults. depression. • Monitor for activities that interrupt the patient’s sleep pattern, Environmental noises and inattention to the patient’s usual sleep such as taking vital signs, daily weights, or treatments. pattern may result in sleep fragmentation. • Plan care activities around periods of least fatigue. Gives attention to the patient’s circadian rhythm. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient and family in identifying risk factors pertinent Provides additional support for the client and family, and uses to the situation: already available resources in a cost-effective manner. � Chronic disease (e.g., arthritis, cancer, or heart disease) � Medications � Pain � Role strain • Teach the client and family measures to promote capacity for physical and mental work: � Use of assistive devices as appropriate (wheelchairs, crutches, canes, walkers, adaptive eating utensils, etc.). � Maintain sufficient pain control (analgesics, imagery, meditation, etc.). � Provide a safe environment to reduce barriers to activity (throw rugs, stairs, blocked pathways, etc) and decrease potential for accidents. � Provide balance of work and recreational activities. � Provide housekeeping assistance as appropriate (e.g., homemaker or meals-on-wheels). • Provide diversional activity as appropriate (visiting friends or family, doing hobbies or schoolwork, etc.). • Consult with or refer to appropriate resources as indicated. Copyright © 2002 F.A. Davis Company FATIGUE 293 Fatigue FLOWCHART EVALUATION: EXPECTED OUTCOME Count number of complaints of fatigue on admission date. Reinterview and compare number of complaints related to fatigue that the patient has today. Has number of complaints decreased? Yes No Record data, e.g., had no complaints of Reassess using initial assessment factors. fatigue in past 24 h as compared with 10 complaints on admission day; reports sleeping much better. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., states “still not sleeping well, wake up often; feel Did evaluation show another worn out nearly all the time.” problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 294 ACTIVITY-EXERCISE PATTERN Gas Exchange, Impaired 9. Confusion 10. Dyspnea DEFINITION 11. Abnormal arterial blood gases 12. Cyanosis (in neonate only) Excess or deficit in oxygenation and/or carbon dioxide elimination 13. Abnormal skin color (pale, dusky) at the alveolar-capillary membrane.21 14. Hypoxemia 15. Hypercarbia NANDA TAXONOMY: DOMAIN 3—ELIMINATION; 16. Headache upon awakening CLASS 4—PULMONARY SYSTEM 17. Abnormal rate, rhythm, and depth of breathing 18. Diaphoresis NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 19. Abnormal arterial pH CLASS K—RESPIRATORY MANAGEMENT 20. Nasal flaring NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS E—CARDIOPULMONARY RELATED FACTORS21 1. Ventilation perfusion imbalance DEFINING CHARACTERISTICS21 2. Alveolar-capillary membrane changes 1. Visual disturbances 2. Increased carbon dioxide RELATED CLINICAL CONCERNS 3. Tachycardia 4. Hypercapnia 1. Chronic obstructive pulmonary disease (COPD) 5. Restlessness 2. Congestive heart failure 6. Somnolence 3. Asthma 7. Irritability 4. Pneumonia 8. Hypoxia 5. Pulmonary tuberculosis HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Airway Clearance This diagnosis dioxide. These gases are sufficiently exchanged at means that something is blocking the air passage the alveoli-circulatory membrane, but the pattern but that, when and if air gets to the alveoli, there is of ventilation makes breathing ineffective. adequate gas exchange. In Impaired Gas Decreased Cardiac Output In this diagnosis, the Exchange, the air (oxygen) that reaches the alveoli heart is not pumping a sufficient amount of blood is not sufficiently diffused across the alveolar- through the lungs to take up enough oxygen or capillary membrane. release enough carbon dioxide to meet the body Ineffective Breathing Pattern This diagnosis requirements. There is no impairment in the gas suggests that the rate, rhythm, depth, and type of exchange, but there is not enough circulating ventilatory effort are insufficient to bring in enough blood to combine with sufficient amounts of oxygen or get rid of sufficient amounts of carbon oxygen to supply the body’s needs. EXPECTED OUTCOME TARGET DATES Will demonstrate improved blood gases and vital signs by [date]. Because of the extreme danger of Impaired Gas Exchange, progress Note initial blood gas measurements and vital signs here. should be evaluated at least every 8 hours until the client has sta- bilized. Thereafter, target dates at 3 to 5 days would be acceptable. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor and document: Baseline factors that will allow assessment of the patient’s progress � Respiratory pattern, rate, and depth at least every 2 h on toward improvement or lack of progress. [odd/even] hour (continued) Copyright © 2002 F.A. Davis Company GAS EXCHANGE, IMPAIRED 295 (continued) ACTIONS/INTERVENTIONS RATIONALES � Symptoms noted with respirations, such as pain, difficulty in breathing, retraction of sternum or flaring of nares, or allergies � Equipment used in ventilation, including ventilator settings for rate, oxygen (FiO2), peak pressure (PP), and if continuous positive airway pressure (CPAP) is needed � Auscultation of breath sounds every 1 h or as needed, with follow-up chest x-ray as needed � Tolerance of chest physiotherapy � Suctioning tolerance, especially pulse rate � Nature of secretions obtained via suctioning � Observations of skin and mucous membranes for cyanosis • Maintenance of fluid and electrolyte balance: � Administer appropriate fluids and electrolytes as ordered. � Monitor hourly intake and output. � Administer potassium only after voiding is noted. � Monitor specific gravity 4 times a day at [times]. • Administer or assist with intermittent positive-pressure Opens airways and alveoli and improves gas exchange. Oxygen breathing (IPPB) or continuous positive airway pressure (CPAP) reduces the work of breathing and thus enhances gas exchange. as ordered. Stay with the patient during treatment. In between treatments, administer oxygen as ordered. • Perform nursing actions to maintain effective airway clearance. Clearing airways of secretions improves ventilation-perfusion (See Ineffective Airway Clearance for nursing actions, and enter relationship. those actions here.) • Decrease the patient’s anxiety during periods of increased distress by: � Talking in a calm, slow voice � Reassuring the patient that you can provide the necessary assistance � Having the patient take slow, deep breaths and follow proper breathing techniques � Staying with the client until episode resolves • Schedule at least 15 min with the patient every 2 h on [odd/even] Assists in reducing fear and anxiety. hour for discussing concerns. • Raise head of bed to 30 degrees or more if not contraindicated. Facilities chest expansion. • Reduce chest pain by using noninvasive techniques and Relaxes muscle tension, decreases oxygen consumption, and analgesics. decreases carbon dioxide production. • Encourage drinking 2–3 L of fluid per day unless contraindicated Assists in liquefying secretions, which makes them easier to expel. by other medical problems, e.g., congestive heart failure. • Maintain adequate nutrition (high protein, low fat, and low Decreases energy demand for digestion, and prevents constriction carbohydrates) on a daily basis. Collaborate with diet therapist of chest cavity as a result of a full stomach. regarding several small meals per day rather than three large meals. • Instruct in diaphragmatic deep breathing and pursed-lip breathing. Give the patient information in clear, concise manner, providing written notes if necessary. This is especially true for the patient who has altered mental status as a result of hypoxia. • Have

the patient practice proper breathing once every hour Essential knowledge needed for the patient to control situation. while awake. These sessions should be supervised by the nurse Will assist in expelling secretions. until the patient masters the technique. Note schedule for practice sessions here. • Provide teaching regarding respiratory exercises: � Assume a sitting position with back straight and shoulders relaxed. � Use conscious, controlled deep-breathing techniques that expand diaphragm downward (abdomen should rise). � Breathe in deeply through the nose, hold for 2–3 s, then breathe out slowly through pursed lips. Abdomen will sink down with the exhalation. • Instruct the patient to perform exercises at least twice an hour while awake. (Practice with and supervise until confident the patient can perform exercises accurately.) (continued) Copyright © 2002 F.A. Davis Company 296 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide teaching regarding bronchial hygiene: � Breathe deeply and slowly while sitting up. � Use diaphragmatic breathing; � Hold the breath for 3–5 s, and then slowly exhale through the mouth as much of the breath as possible. � Take another deep breath, hold, and cough forcefully from deep in the chest. Repeat 2 times. � Rest 15–20 min after coughing session. • Assist with postural drainage and cupping and clapping exercises. Teach these exercises to significant other. • Administer bronchodilators and mucolytic agents as ordered. • Collaborate with physician regarding monitoring of blood gases; PCO2, PO2, and O2 saturation are indicators of the efficiency of gas report abnormal results immediately. exchange. • Turn every 2 h on [odd/even] hour. Encourage the patient’s Position changes modify ventilation-perfusion relationships and mobility to the extent tolerated without dyspnea. enhance gas exchange. • Develop a schedule, on day of admission, for activity and rest Conserves energy needed for breathing and gas exchange. that provides the patient with the greatest amount of activity with the least amount of fatigue, e.g., have chair in bathroom for being seated while doing daily hygiene. Note schedule here. • Discuss with the patient the effects smoking has on the Smoking, or passive smoke for the nonsmoker, greatly increases respiratory system, and refer the patient to a stop smoking the risk for development of respiratory and cardiovascular diseases. group if the patient is motivated to stop smoking; if not, Smoking immediately before eating or exercise causes instruct the patient not to smoke 15 min before meals and vasoconstriction, leading to decreased gas exchange and physical activity. compounding condition. • Review the patient’s resources and home situation regarding Initiates appropriate home care planning and long-range support long-term management of Impaired Gas Exchange prior to for the patient and family. discharge. Refer to appropriate community resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Ensure availability of emergency equipment: Basic emergency preparedness. � Ambu bag � Endotracheal tube appropriate for age and size of infant (3.5) � Suctioning unit and catheters: infant, 5 or 8 Fr; child, 8 or 10 Fr � Crash cart with appropriate drugs � Defibrillation unit with guidelines � O2 tank (check amount of oxygen left) � Tracheostomy sterile set � Sterile chest tube tray • Provide for parental input in planning and implementing care, Parental involvement provides emotional security for the child’s e.g., comfort measures, assisting with feedings, and daily parents; offers empowerment and allows practicing of care hygienic measures. techniques in a supportive environment. • Allow at least 10–15 min per shift for the family to verbalize Assists in reducing anxiety, and provides teaching opportunity. concerns regarding the child’s status and changes. Encourage the parents to ask questions as often as needed. • Collaborate with related health care team members as needed. Promotes coordination of care without undue duplication and fragmentation of care. • While the child is still in the hospital, provide opportunities for Learning of essential skills is enhanced when opportunities for the parents and child to master essential skills necessary for practice are allowed in a safe, secure environment. Compliance is long-term care, such as suctioning. also fostered. • Ensure that the parents and family receive CPR training well Anticipatory need for CPR should better prepare parents and other before dismissal from hospital. family members in the event of pulmonary arrest. Having this basic knowledge will assist in reducing anxiety regarding home care. • Encourage the parents to use support system to aid in coping Reliance on others should afford the parents some degree of relief with illness and hospitalization. from constant worry based on the likelihood of primary needs with a chronically ill child. • Allow for sibling visitation as applicable within institution or Sibling visitation enhances the opportunity for family coping and specific situation. growth. Provides moral support to both siblings. Copyright © 2002 F.A. Davis Company GAS EXCHANGE, IMPAIRED 297 Women’s Health NOTE: This nursing diagnosis will pertain to women the same as in any other adult. The following nursing actions only focus will on the fetal-placental unit during pregnancy. Placental function is to - tally dependent on maternal circulation; therefore, any process that interferes with maternal circula - tion will affect the oxygen consumption of the placenta and, in turn, the fetus. ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in developing an exercise plan during Increases cardiovascular fitness, and therefore increases oxygenation pregnancy. and nutrition to placenta and fetus. • Teach the patient and significant others how to avoid “supine hypotension” during pregnancy (particularly during the later stages): � Lying on right or left side to reduce pressure on vena cava � Taking frequent rest breaks during the day • Assist the patient in identifying lifestyle adjustments that may be needed because of changes in physiologic function or needs during pregnancy: � Stop smoking. � Reduce exposure to secondhand smoke. � Avoid lying in supine position. � Take no drugs unless advised to do so by physician. • Identify underlying maternal diseases that will affect the These disorders have direct impact on the gas exchange in the fetal-placental unit during pregnancy: fetal-placental unit. � Maternal origin: (1) Maternal hypertension (2) Drug addiction (3) Diabetes mellitus with vascular involvement (4) Sickle cell anemia (5) Maternal infections (6) Maternal smoking (7) Hemorrhage (abruptio placentae or placenta previa) � Fetal origin: (1) Premature or prolonged rupture of membranes (2) Intrauterine infection (3) Rh disease (4) Multiple pregnancy Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • If the client is demonstrating alterations in mental status, The central nervous system is particularly sensitive to impaired gas assess for increased hypoxia. exchange because of its reliance on simple sugar metabolism for energy production.67 • Observe the client for signs of respiratory infection. Infection will increase mucus production, which decreases airway clearance.67 • Protect the client from respiratory infection by: Prevents further injury to a system that is stressed, and promotes � Maintaining proper humidity in environment. airway patency. � Placing him or her in private room or monitoring roommate closely for signs and symptoms of respiratory infection and, if present, moving the client to another room. � Assigning staff members to the client who are free of infection. � Keeping the client away from crowds. � Assisting the client in obtaining appropriate immunizations against influenza. � Having the client inform staff of signs or symptoms of respiratory infection when the earliest symptoms appear. � Keeping environment as free of respiratory irritants as possible, e.g., dust, allergens, or pollution. (continued) Copyright © 2002 F.A. Davis Company 298 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client the effects of alcohol and other The sedative effects of some drugs decrease airway clearance, depressant drugs on the respiratory system. Refer to a increasing the risk for the development of infection. Diffusion is drug-abuse recovery program as necessary. also decreased with chronic alcoholism.77 • Collaborate with physician regarding supplemental vitamins, Thiamine is essential for the conversion of glucose to metabolically especially thiamine, if the impaired gas exchange is secondary useful forms. Nerve cell function depends on this glucose. This to alcohol abuse. compensates for the nutritional deficits that result when nutritional calories are replaced by alcohol.78 • Spend 30 min twice a day with the client discussing feelings and Promotes the client’s sense of control by facilitating understanding reactions to current situation. As feelings are expressed, begin to of factors that contribute to maladaptive coping behaviors. explore lifestyle changes with the client. Refer to Ineffective Individual Coping (Chap. 11) and Powerlessness (Chap. 8) for specific care plans related to coping styles. • Develop with the client a plan for gradually increasing physical Improves cardiorespiratory functioning, thus improving gas activity (see Activity Intolerance for specific behavioral exchange. interventions). Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Ensure that oxygen delivery system is properly functioning and Basic care standards. fits well. Avoid face mask if the patient is emaciated. Check proper positioning of nasal cannula (prongs turned inward). • Monitor skin color, mental status, and vital signs every 2 h on [odd/even] hour. • Check oxygen flow and amount every 4 h around the clock at The patient may increase the liter flow during acute episodes of [times]. impaired gas exchange and cause respiratory system depression with retention of carbon dioxide. • Monitor for potential carbon dioxide narcosis, e.g., changes in level of consciousness, changes in oxygen and carbon dioxide blood gas levels, flushing, decreased respiratory rate, and headaches. This is especially important for a patient on long-term oxygen therapy.60 • Teach the patient and family the signs and symptoms of carbon Decreases potential for carbon dioxide narcosis. dioxide narcosis, especially those on long-term oxygen therapy. Home Health NOTE: If this diagnosis is suspected when caring for a client in the home, it is imperative that a physi- cian referral be obtained immediately. If a physician has referred the client to home health care, the nurse will collaborate with the physician in the treatment of the client. Preliminary research77 indicates that women with chronic bronchitis or chronic obstructive pulmonary disease (COPD) cannot walk as far as men. Activity should be planned according to tolerance, keeping in mind gender differences. There is no doubt that better control of dyspnea is a pressing need, with research79 indicating that a client’s subjective report of health status is a better predictor of level of functioning than is objective measure of the lung function. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides for early recognition and intervention for problem. symptoms of Impaired Gas Exchange: � Pursed-lip breathing � Respiratory status: cyanosis, rate, dyspnea, or orthopnea � Fatigue � Use of accessory muscles � Cough � Sputum production or change in sputum production � Edema � Decreased urinary output � Gasping (continued) Copyright © 2002 F.A. Davis Company GAS EXCHANGE, IMPAIRED 299 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Prevention of Impaired Gas Exchange: Stopping smoking, prevention or early treatments of lung infections, avoidance of known irritants and allergens, obtaining influenza and pneumonia immunizations � Pulmonary hygiene: Clearing bronchial tree by controlled coughing, decreasing viscosity of secretions via humidity and fluid balance, and postural drainage � Daily activity as tolerated (remove barriers to activity) � Breathing techniques to decrease work of breathing (diaphragmatic, pursed lips, or sitting forward) � Adequate nutrition intake � Appropriate use of oxygen (dosage, route of administration, safety factors) � Stress management � Limiting exposure to upper respiratory infections � Avoiding extreme hot or cold temperatures � Keeping area free of animal hair and dander or dust � Assistive devices required (oxygen, nasal cannula, suction, ventilator, etc.) � Adequate hydration (monitor intake and output) • Teach the client and family purposes, side effects, and proper administration technique of medications. • Assist the client and family to set criteria to help them determine Locus of control shifts from nurse to the client and family, thus when calling a physician or other intervention is required, e.g., promoting self-care. change in skin color, increased difficulty with breathing, increase or change in sputum production, or fever. • Teach the family basic CPR. • Refer to community resources as needed. Provides additional support for the client and family, and uses already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company 300 ACTIVITY-EXERCISE PATTERN Gas Exchange, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Are the

patient’s blood gases within normal limits? Yes No Are patients vital signs within normal limits? No Reassess using initial assessment factors. Yes Record data, e.g., pO2 pCO2 within normal limits (state exact measurements No Is diagnosis validated? here); vital signs are T 98.4, P 76, R 18, BP 128/84. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., pO2 still below normal, pCO2 elevated (state Did evaluation show another exact measurements here); vital problem had arisen? Yes signs are T 98.8, P 86, R 26, BP 148/102. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company GROWTH AND DEVELOPMENT, DELAYED; DISPROPORTIONATE GROWTH, RISK FOR; DELAYED DEVELOPMENT, RISK FOR 301 Growth and Development, Delayed; C. Risk for Delayed Development 1. Prenatal Disproportionate Growth, Risk for; a. Maternal age 15 or 35 years Delayed Development, Risk for b. Substance abuse c. Infections DEFINITIONS21 d. Genetic or endocrine disorders e. Unplanned or unwanted pregnancies Delayed Growth and Development The state in which an indi- f. Lack of, late, or poor prenatal care vidual demonstrates deviations in norms from his or her age group. g. Inadequate nutrition Risk for Disproportionate Growth At risk for growth above the h. Illiteracy 97th percentile or below the 3rd percentile for age, crossing two i. Poverty percentile channels, or disproportionate growth. 2. Individual a. Prematurity Risk for Delayed Development At risk for delay of 25 percent or b. Seizures more in one or more of the areas of social or self-regulatory behav- c. Congenital or genetic disorders iors, or cognitive, language, gross, or fine motor skills. d. Positive drug screening test e. Brain damage (e.g., hemorrhage in postnatal period, NANDA TAXONOMY: DOMAIN 13—GROWTH/ shaken baby, abuse, accident) DEVELOPMENT; CLASS 1—GROWTH AND f. Vision impairment CLASS 2—DEVELOPMENT g. Hearing impairment or frequent otitis media NIC: DOMAIN 5—FAMILY; CLASS Z— h. Chronic illness CHILDREARING CARE i. Technology-dependent j. Failure to thrive NOC: DOMAIN I—FUNCTIONAL HEALTH; k. Inadequate nutrition CLASS B—GROWTH AND DEVELOPMENT l. Foster or adopted child m. Lead poisoning DEFINING CHARACTERISTICS21 n. Chemotherapy o. Radiation therapy A. Delayed Growth and Development p. Natural disaster 1. Altered physical growth q. Behavioral disorder 2. Delay or difficulty in performing skills (motor, social, or ex- r. Substance abuse pressive) typical of age group 3. Environmental 3. Inability to perform self-care or self-control activities appro- a. Poverty priate to age b. Violence 4. Flat affect 4. Caregiver 5. Listlessness a. Abuse 6. Decreased responses b. Mental illness B. Risk for Disproportionate Growth c. Mental retardation or severe learning disability 1. Prenatal a. Congenital or genetic disorders b. Maternal nutrition RELATED FACTORS21 c. Multiple gestation d. Teratogen exposure A. Delayed Growth and Development e. Substance use or abuse 1. Prescribed dependence f. Infection 2. Indifference 2. Individual 3. Separation from significant others a. Infection 4. Environmental and stimulation deficiencies b. Prematurity 5. Effects of physical disability c. Malnutrition 6. Inadequate caretaking d. Organic and inorganic factors 7. Inconsistent responsiveness e. Caregiver and/or individual maladaptive feeding behaviors 8. Multiple caretakers f. Anorexia B. Risk for Disproportionate Growth g. Insatiable appetite The risk factors also serve as the related factors. h. Chronic illness C. Risk for Delayed Development i. Substance abuse The risk factors also serve as the related factors. 3. Environmental a. Deprivation RELATED CLINICAL CONCERNS b. Teratogen c. Lead poisoning 1. Hypothyroidism d. Poverty 2. Failure to thrive syndrome e. Violence 3. Leukemia f. Natural disasters 4. Deficient growth hormone 4. Caregiver 5. Personality disorders a. Abuse 6. Schizophrenic disorders b. Mental illness 7. Substance abuse c. Mental retardation 8. Dementia d. Severe learning disability 9. Delirium Copyright © 2002 F.A. Davis Company 302 ACTIVITY-EXERCISE PATTERN HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Sensory Perception This diagnosis Imbalanced Nutrition, Less Than Body should be considered when blindness, deafness, or Requirements Lack of essential vitamins and neurologic impairment is present. Assisting the minerals will also show a direct link to Delayed patient to adapt to these problems could resolve Growth and Development. Assessment should be any developmental problems. implemented for both diagnoses. Impaired Physical Mobility When physical The nursing diagnoses grouped under Self- disabilities are present, they can definitely impact Perception and Self-Concept Pattern, Role- growth and development. In this example, Relationship Pattern, and Coping-Stress Tolerance Impaired Physical Mobility and Delayed Growth Pattern should also be considered when alterations and Development would be companion diagnoses. in growth and development are present. EXPECTED OUTCOME TARGET DATES Will return, as nearly as possible, to expected growth and develop- Assisting in modifying Delayed Growth and Development factors ment parameter for [specify exact parameter] by [date]. will require significant time; therefore, an initial target date of 7 to 10 days would be reasonable for evaluating progress. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: Nursing actions for this diagnosis are varied and complex and incorporate nursing actions as- sociated with other nursing diagnoses. For example, the patient may have either a total self-care deficit or a subdeficit in hygiene, grooming, feeding, or toileting. For an adult, any of these would be an al- teration in growth and development. Therefore, it would be appropriate to include the nursing actions associated with these nursing diagnoses in the nursing actions for Delayed Growth and Development. An adult is generally able to find or initiate diversional and social activities. However, if the adult does not participate in diversional or social activities, it could indicate Delayed Growth and Develop- ment. Therefore, the nursing actions associated with Deficient Diversional Activity and Social Isolation would be appropriate to be included in the nursing actions for Delayed Growth and Development. ACTIONS/INTERVENTIONS RATIONALES • In general, the nurse should provide adequate opportunities for Success increases motivation. the patient to be successful in whatever task he or she is attempting. • Reward and reinforce success, however minor. Downplay Increases self-esteem and active participation in care. relapses. Allow the patient to be as independent as possible. • Have consistent, nonjudgmental, caring people in the caregiving Caring people instill confidence in a patient and willingness to try role. new tasks. • Work collaboratively with other health care professionals and Facilitates development of a plan that all will use consistently. with the patient and family in developing a plan of care. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor and teach the parents to monitor the child’s growth and As a rule, single assessments are not as revealing in growth and development status. Determine what alterations there are (i.e., development parameters as are serial, longitudinal patterns. delays or precocity). Parental involvement offers a more thorough monitoring, fosters their involvement with the child, and empowers the family. • Determine what other primary health care needs exist, especially In instances of brain damage or retardation, it is often difficult to get brain damage or residual of brain damage. an accurate assessment of cognitive capability. The general health of the patient will often influence, to a major degree, what alteration in cognitive functioning exists, e.g., sickle cell anemia with resultant infarcts to major organs such as the brain. (continued) Copyright © 2002 F.A. Davis Company GROWTH AND DEVELOPMENT, DELAYED; DISPROPORTIONATE GROWTH, RISK FOR; DELAYED DEVELOPMENT, RISK FOR 303 (continued) ACTIONS/INTERVENTIONS RATIONALES • Identify, with the child or the parents, realistic goals for growth A plan of care based on individual needs, with parental input, and development. better reflects holistic care and increases probability of effective home management of problem. • Collaborate with related health care team members as necessary. Collaboration is required for meeting the special long-term needs for activities of daily living. • Identify anticipatory safety for the child related to Delayed These children may be large physically because of chronologic age, Growth and Development, e.g., ingestion of objects, falls, or use and there is a possibility of overlooking the developmental or of wheelchair. mental age. • In case of special diet necessitated by a metabolic component, Appropriate diet can assist in preventing further deterioration or be e.g., various enzymes lacking, provide appropriate health essential to replace lacking vitamins, enzymes, or other nutrients. teaching for the parents. • Refer the child and parents to appropriate community resources Offering early intervention assists in fostering development, while to assist in fostering growth and development, such as the early preventing tertiary delays. childhood intervention services. • Assist the parents to provide for learning needs related to future Appropriate match of services to needs enhances the child’s development, including identification of schools for development to the highest level possible. developmentally delayed children. • Refer the child and parents to state and national support groups Support groups assist in empowerment and advocacy at local, state, such as National Cerebral Palsy Association. and national levels. • Provide the patient and family with long-term follow-up Promotes implementation of management regimen, and provides appointments before discharge. anticipatory resources and checkpoint for the patient and family. Women’s Health NOTE: This nursing diagnosis will pertain to women the same as to any other adult. The following nursing actions pertain only to women with reproductive anatomic abnormalities. The mother does need to be aware of the normal growth patterns in order to assess the health and development of her child. See Child Health. ACTIONS/INTERVENTIONS RATIONALES • Obtain a thorough sexual and obstetric history, especially noting Provides basic database for determining therapy needs. recurrent miscarriages in the first 3 months of pregnancy. • Collaborate with physician regarding assessment for infertility. • Refer to gynecologist for further testing if primary amenorrhea is present. • Encourage the patient to verbalize her concerns and fears. Decreases anxiety. Allows opportunity for teaching, and allows correction of any misinformation. • Encourage communication with significant others to identify Provides a base for teaching and long-range counseling. concerns and explore options available. Psychiatric Health NOTE: If anorexia nervosa is the underlying cause for growth risk, refer to the Psychiatric Health care plan for the diagnosis Imbalanced Nutrition, Less Than Body Requirements, for the appropriate intervention. ACTIONS/INTERVENTIONS RATIONALES • Provide a quiet, nonstimulating environment or an environment Too little or too much sensory input can result in a sense of that does not add additional stress to an already overwhelmed disorganization and confusion and result in dysfunctional coping coping ability. behaviors.33 • Sit with the client [number] minutes [number] times per day at Attention from the nurse can enhance self-esteem. Expression of [list specific times] to discuss current concerns and feelings. feelings can facilitate identification and resolutions of problematic coping behaviors. • Provide the client with familiar or needed objects. These should Promotes the client’s sense of control by providing an environment be noted here. in which the client feels safe and secure. • Discuss with the client perceptions of self, others, and the Provides positive orientation, which improves self-esteem and current situation. This should include the client’s perceptions of provides hope for the future. harm, loss, or threat. Assist the client in altering perception of these situations so they can be seen as challenges or opportunities for growth rather than threats. (continued) Copyright © 2002 F.A. Davis Company 304 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide the client with an environment that will optimize Appropriate levels of sensory input promote contact with the reality sensory input. This could include hearing aids, eyeglasses, of the environment, which facilitates appropriate coping. pencil and paper, decreased noise in conversation areas, and appropriate lighting. (These interventions should indicate an awareness of sensory deficit as well a sensory overload, and the specific interventions for the client should be noted here, e.g., place hearing aid in when the client awakens, and remove before bedtime.) • Provide the client with achievable tasks, activities, and goals Provides positive reinforcement, which enhances self-esteem and (these should be listed here). These activities should be provided provides motivation for working toward next goal. with increasing complexity to give the client an increasing sense of accomplishment and mastery. • Communicate to the client an understanding that all coping Promotes positive orientation, which enhances self-esteem and behavior to this point has been his or her best effort and asking promotes hope. for assistance at this time is not failure. Explain that a complex problem often requires some

outside assistance in resolution. (This will assist the client in maintaining self-esteem and diminish feelings of failure.) • Provide the client with opportunities to make appropriate Promotes the client’s perception of control, which promotes decisions related to care at his or her level of ability. This may self-esteem. begin as a choice between two options and then evolve into more complex decision making. It is important that this be at the client’s level of functioning so confidence can be built with successful decision-making experiences. • Provide constructive confrontation for the client about Provides opportunities for the client to question aspects of behavior problematic coping behavior. (See Wilson and Kneisl32 for that can promote desire to change. guidelines on constructive confrontation.) The kinds of behavior identified by the treatment team as problematic should be listed here. • Provide the client with opportunities to practice new kinds of Provides opportunities to practice new behavior in a safe behavior either by role playing or by applying them to graded environment where the nurse can provide positive feedback for real-life experiences. gradual improvement of coping strategies. This increases probability for the success of the new behavior in real-life situation, which in turn serves as positive reinforcement for behavior change. • Provide positive social reinforcement and other behavioral Positive reinforcement encourages appropriate behavior. rewards for demonstration of adaptive behavior. (Those things that the client finds rewarding should be listed here with a schedule for use. The kinds of behavior that are to be rewarded should also be listed.) • Assist the client in identifying support systems and in Support systems can provide positive reinforcement for behavior developing a plan for their use. change, increasing the opportunities for the client’s success enhancing self-esteem. • Assist the client with setting appropriate limits on aggressive Excessive environmental stimuli can increase a sense of behavior by (see Risk for Violence, Chap. 9, for detailed nursing disorganization and confusion. actions if this is an appropriate diagnosis): � Decreasing environmental stimulation as appropriate. (This might include a secluded environment.) � Providing the client with appropriate alternative outlets for Promotes a sense of control, and teaches constructive ways to physical tension. (This should be stated specifically and could cope with stressors. include walking, running, talking with a staff member, using a punching bag, listening to music, or doing a deep muscle relaxation sequence. These outlets should be selected with the client’s input). • Meet with the client and support system to provide information Enhances opportunities for success of the treatment plan. on the client’s situation and to develop a plan that will involve the support system in making changes that will facilitate the client’s movement to age-appropriate behavior. Note this plan here. • Refer to appropriate assistive resources as indicated. Copyright © 2002 F.A. Davis Company GROWTH AND DEVELOPMENT, DELAYED; DISPROPORTIONATE GROWTH, RISK FOR; DELAYED DEVELOPMENT, RISK FOR 305 Gerontic Health Nursing interventions provided in the Adult Health and Home Health sections for this diagnosis may be enhanced for the older client with the addition of the following actions. ACTIONS/INTERVENTIONS RATIONALES • Provide opportunities for clients to reflect on their strengths and Promotes ability to obtain perspective on life experiences.80 Provides life accomplishments through activities such as life review, potential for enhancing life satisfaction.80 reminiscing, and oral or written autobiographies. • Consult with physician for potential assessment and treatment Depression often goes undetected in older adults and may of depression. negatively impact their ability to effectively cope with losses and to positively appraise their current situation.80 • Ask older clients what tasks of aging they have defined for Promotes discussion of the older adult’s expectations.81 themselves. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to Delayed Growth and Provides database for prevention and/or early intervention. Development. • Involve the client and family in planning, implementing, and Involvement improves motivation and improves the outcome. promoting reduction or correction of the delay in growth and development: � Family conference � Mutual goal setting � Communication • Teach the client and family measures to prevent or decrease Locus of control shifts from nurse to the client and family, thus delays in growth and development: promoting self-care. � Explain expected norms of growth and development with anticipatory guidance. If the caretakers realize, for example, that the newborn begins to roll over by 2–4 mo or that the 2-year-old can follow simple directions, then appropriate environmental and learning conditions can be provided to protect the child and to promote optimal development. � Alert the parents to signs and symptoms of alterations in growth and development that may require professional evaluation, e.g., delay in language skills, delay in crawling or walking, or delay in growth below 50 percent on growth chart. � Discuss parenting skills, e.g., how to recognize developmental milestones and how to discipline effectively without violence. � Provide guidance on developmentally appropriate nutrition, e.g., how to introduce finger foods to toddlers, how to monitor calorie intake for expected developmental stage, and how to ensure a balanced diet. • Assist the client and family to identify lifestyle changes that may Provides basic information for the client and family that promotes be required: necessary lifestyle changes. � Care for handicaps (e.g., blindness, deafness, or musculoskeletal or cognitive deficit) � Proper use of assistive equipment � Adapting to need for assistance or assistive equipment � Determining criteria for monitoring the client’s ability to function unassisted � Time management � Stress management � Development of support systems � Learning new skills � Work, family, social, and personal goals and priorities � Coping with disability or dependency (continued) Copyright © 2002 F.A. Davis Company 306 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Development of consistent routine � Mechanism for alerting family members to the need for assistance � Providing appropriate balance of dependence and independence • Assist the client and family to obtain assistive equipment as Assistive equipment improves function and increases the required (depending on alteration present and its severity): possibilities for self-care. � Adaptive equipment for eating utensils, combs, brushes, etc. � Straw and straw holder � Wheelchair, walker, motorized cart, or cane � Bedside commode or incontinence undergarments � Hearing aid � Corrective lenses � Dressing aids: dressing stick, zipper pull, button hook, long-handled shoehorn, shoe fasteners, or Velcro closures � Bars and attachments and benches for shower or tub � Handheld shower device � Medication organizers � Magnifying glass � Raised toilet seat • Consult with appropriate assistive resources as indicated. Provides additional support for the client and family, and uses already available resources in a cost-effective manner. • Assist the client or caregivers in obtaining prescribed Promotes adherence to therapeutic regimen. medications, and ensure that they understand doses, administration times, therapeutic effects, and possible side effects. • If the client is a child, the nurse can serve as a liaison between Provides continuity of care. the school nurse, family, and primary physician to monitor effectiveness of therapy and to provide anticipatory guidance for family members. • Instruct the client as appropriate and the caregivers to maintain Consistency can promote success and focus on strengths of the a consistent home environment (e.g., schedules, parenting, and client. goal setting). The home environment should be free of distractions when it is necessary for the client to perform tasks. • Refer clients and family members for counseling, special training Helps develop healthier self-esteem and positive coping strategies. (e.g., parenting classes), or support groups as necessary. Copyright © 2002 F.A. Davis Company GROWTH AND DEVELOPMENT, DELAYED; DISPROPORTIONATE GROWTH, RISK FOR; DELAYED DEVELOPMENT, RISK FOR 307 Growth and Development, Delayed; Disporportionate Growth, Risk for; Delayed Development, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient returned to extent possible to the stated parameters? Yes No Record data, e.g., has gained 10 lb Reassess using initial assessment factors. over past 6 wk; is demonstrating ability to roll over and sit up by self. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has gained 3 lb over past 3 wk but is still Did evaluation show another 6 lb underweight for age; can problem had arisen? Yes roll over by self but still has difficulty standing alone. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 308 ACTIVITY-EXERCISE PATTERN Home Maintenance, Impaired 2. Subjective a. Household members express difficulty in maintaining their DEFINITION home in a comfortable fashion. b. Household members describe outstanding debts or financial Inability to independently maintain a safe growth-promoting crises. immediate environment.21 c. Household members request assistance with home mainte- nance. NANDA TAXONOMY: DOMAIN 1—HEALTH PROMOTION; CLASS 2—HEALTH MANAGEMENT RELATED FACTORS21 NIC: DOMAIN 5—FAMILY; CLASS X—LIFE SPAN 1. Individual or family member disease or injury CARE 2. Unfamiliarity with neighborhood resources NOC: DOMAIN VI—FAMILY HEALTH; CLASS X— 3. Lack of role modeling FAMILY WELL-BEING 4. Lack of knowledge 5. Insufficient family organization or planning 6. Impaired cognitive or emotional functioning DEFINING CHARACTERISTICS21 7. Inadequate support systems 8. Insufficient finances 1. Objective a. Overtaxed family members, for example, exhausted, anxious b. Unwashed or unavailable cooking equipment, clothes, or linen RELATED CLINICAL CONCERNS c. Repeated hygienic disorders, infestations, or infections 1. Dementia problems, such as Alzheimer’s disease d. Accumulation of dirt, food wastes, or hygienic wastes 2. Rheumatoid arthritis e. Disorderly surroundings 3. Depression f. Presence of vermin or rodents 4. Cerebrovascular accident g. Inappropriate household temperature 5. Acquired immunodeficiency syndrome (AIDS) h. Lack of necessary equipment or aids i. Offensive odors HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Activity Intolerance If the nurse observes or Most likely, Impaired Home Management would validates reports of the patient’s inability to be a companion diagnosis. complete required tasks because of insufficient Ineffective Individual Coping or Compromised or energy, then Activity Intolerance would be the Disabled Family Coping Suspect one of these more appropriate diagnosis. diagnosis if there are major differences between Deficient Knowledge The problem with home reports by the patient and the family of health maintenance may be due to the family’s lack of status, health perception, and health care education regarding the care needed and the behavior. Verbalizations by the patient or the environment that is essential to promote this care. If family regarding inability to cope also require the patient or family verbalizes less-than-adequate looking at these diagnoses. understanding of home maintenance, then Deficient Interrupted Family Processes Through observing Knowledge is the more appropriate diagnosis. family interactions and communication, the nurse Disturbed Thought Process If the patient is may assess that Interrupted Family Processes exhibiting impaired attention span; impaired should be considered. Poorly communicated ability to recall information; impaired perception, messages, rigidity of family functions and roles, judgment, and decision making; or impaired and failure to accomplish expected family conceptual and reasoning ability, the most proper developmental tasks are a few observations to alert diagnosis would be Disturbed Thought Process. the nurse to this possible diagnosis. EXPECTED OUTCOME TARGET DATES Will demonstrate alterations necessary to reduce Impaired Home Target dates will depend on the severity of the Impaired Home Maintenance by [date]. Maintenance. Acceptable target dates for the first evaluation of progress toward meeting this outcome would be 5 to 7 days. Copyright © 2002 F.A. Davis Company HOME MAINTENANCE, IMPAIRED 309 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health A nurse in an acute care facility might very well receive enough information while the patient is hospital- ized to make this nursing diagnosis. However, nursing actions specific for this diagnosis will require im- plementation in the home environment; therefore, the reader is referred to the Home Health nursing ac- tions for this diagnosis. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor risk factors of or contributing factors to Impaired Provides primary database for intervention. Home Maintenance, to include: � Addition of a family member, e.g., birth � Increased burden of care as a result of the child’s illness or hospitalization � Lack of sufficient finances � Loss of family member, e.g., death � Hygienic practices � History of repeated infections or poor health management � Offensive odors • Identify ways to deal with home maintenance alterations with Coordinated activities will be required to meet the entire range of

assistance of applicable health team members. needs related to improving problems with home maintenance. • Allow for individual patient and parental input in plan for Parental input offers empowerment and attaches value to family addressing home maintenance issues. preferences. This in turn increases the likelihood of compliance. • Monitor educational needs related to illness and the demands of Monitoring of educational needs balanced with the home situation the situation, e.g., mom who must attend to a handicapped will best provide a base for intervention. child and six other children with various school appointments, health care appointments, etc. • Provide health teaching with sensitivity to the patient and family Teaching to address identified needs reduces anxiety and promotes situation, e.g., seeming inability to manage with overwhelming self-confidence in ability to manage. demands of the child’s need for care, such as a premature infant or a child with cerebral palsy who has feeding difficulties. • Provide 10–15 min each 8-h shift as a time for discussion of Setting aside times for discussion shows respect and assigns value patient and family feelings and concerns related to health to the patient and family. management. • Encourage the patient and family to identify support groups in Support groups empower and facilitate family coping. the community. • If the infant is at risk for sudden infant death syndrome (SIDS) When risk factors for pulmonary arrest are present as, for example, by nature of prematurity or history of previous death in family, for a SIDS infant, family members will be less anxious if they are assist parents in learning about alarms and monitoring taught CPR techniques and given opportunities to rehearse and respiration, and institute CPR teaching. master these techniques. • Provide for appropriate follow-up after dismissal from hospital. Follow-up plans provide a means of further evaluation for progress in coping with home maintenance. Ideally, actual home visitation allows the best opportunity for monitoring goal achievement. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client to describe her perception or understanding of Provides database needed to plan changes that will increase ability home maintenance as it relates to her lifestyle and lifestyle in home maintenance. decisions. Include stress-related problems and effects of environment: � Allow the patient time to describe work situation. � Allow the patient time to describe home situation. � Encourage the patient to describe how she manages her responsibilities as a mother and a working woman. (continued) Copyright © 2002 F.A. Davis Company 310 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Encourage the patient to describe her assets and deficits as she perceives them. � Encourage the patient to list lifestyle adjustments that need to be made. � Monitor identified possible solutions, modifications, etc., designed to cope with each adjustment. � Teach the client relaxation skills and coping mechanisms. • Consider the patient’s social network and significant others: � Identify significant others in the patient’s social network. � Involve significant others if so desired by the patient in discussion and problem-solving activities regarding lifestyle adjustments. • Encourage the patient to get adequate rest: Fatigue can be a major contributor to impaired home maintenance. � Take care of self and baby only. � Let significant others take care of the housework and other children. � Learn to sleep when the baby sleeps. � Have specific, set times for friends or relatives to visit. � If breastfeeding, significant other can change the infant and Both the parents and infant get more rest. The baby begins to nurse bring the infant to the mother at night so that the mother longer and sleep for longer periods of time. does not always have to get up for the infant. Or the mother can sleep with the infant. � Cook several meals at one time for the family and freeze them for later use. � Prepare baby formula for a 24-h period and refrigerate for later use. � Freeze breast milk, emptying breast after the baby eats; significant other can then feed the infant one time at night so the mother can get adequate, uninterrupted sleep. � Put breast milk into bottle and directly into freezer: (1) Milk can be added each time breasts are pumped until needed amount is obtained. (2) Milk can be frozen for 6 wk if needed. (3) To use, milk should be removed from freezer and allowed to thaw to room temperature. (4) Once thawed, must be used within a 12- to 24-h period. Do not refreeze. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client his or her concerns about returning home. Promotes the client’s sense of control, which enhances self-esteem. • Develop with the client and significant others a list of potential Promotes the client’s and support system’s sense of control, which home maintenance problems. increases the willingness of the client to work on goals. • Teach the client and family those tasks that are necessary for Provides opportunities for positive reinforcement of approximation home care. Note tasks and teaching plan here. of goal achievement. • Provide time to practice home maintenance skills, at least 30 min once a day. Medication administration could be evaluated with each dose by allowing the client to administer own medications. The times and types of skills to be practiced should be listed here. • If financial difficulties prevent home maintenance, refer to social services or a financial counselor. • If the client has not learned skills necessary to cook or clean Provides opportunities to practice new skills in a safe environment home, arrange time with occupational therapist to assess for and to receive positive reinforcement for approximation of goal ability and to teach these skills. Support this learning on unit by achievement. [check all that apply]: � Having the client maintain own living area. � Having the client assist with the maintenance of the unit (state specifically those chores the client is responsible for). � Having the client assist with the planning and preparation of unit meals when this is a milieu activity. � Having the client clean and iron own clothing. (continued) Copyright © 2002 F.A. Davis Company HOME MAINTENANCE, IMPAIRED 311 (continued) ACTIONS/INTERVENTIONS RATIONALES • If special aids are necessary for the client to maintain self successfully, refer to social services for assistance in obtaining these items. • If the client needs periodic assistance in organizing self to maintain home, refer to homemaker service or other community agency. • If meal preparation is a problem, refer to community agency for meals-on-wheels, or assist the family with preparing several meals ahead of time or exploring nutritious, easy ways to prepare meals. • Determine with the client a list of rewards for meeting the Positive reinforcement encourages the maintenance of new established goals for achievement of home maintenance, and behavior. then develop a schedule for the rewards. Note the reward schedule here. • Assess environment for impairments to home maintenance, and develop with the client and family a plan for resolving these difficulties (e.g., recipes that are simplified and written in large print to make them easier to follow). • Provide appropriate positive verbal reinforcers for Positive reinforcement encourages maintenance of new behaviors. accomplishment of goals or steps toward the goals. • Utilize group therapy once a day to provide: � Positive role models � Peer support � Realistic assessment of goals � Exposure to a variety of problem solutions � Socialization and learning of social skills Gerontic Health Nursing actions for Adult and Home Health are appropriate for the older adult. The nurse may provide information on resources that target the elderly, such as the area Agency on Aging, local support groups for people with chronic illnesses, and city, county, or state resources for the elderly. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor factors contributing to Impaired Home Maintenance Provides database for prevention and/or early intervention. (items listed under related factors section). • Involve the patient and family in planning, implementing, and Involvement improves motivation and improves the outcome. promoting reduction in the Impaired Home Maintenance: � Family conference � Mutual goal setting � Communication � Family members given specified tasks as appropriate to reduce the Impaired Home Maintenance (shopping, washing clothes, disposing of garbage and trash, yard work, washing dishes, meal preparation, etc.) • Assist the patient and family in lifestyle adjustments that may be Provides basic information for the client and family that promotes required: necessary lifestyle changes. � Hygiene practices � Elimination of drug and alcohol use � Stress management techniques � Family and community support systems � Removal of hazardous environmental conditions, such as improper storage of hazardous substances, open heaters and flames, breeding areas for mosquitos or mice, or congested walkways � Proper food preparation and storage • Refer the patient and family to appropriate assistive resources as Provides additional support for the client and family, and uses indicated. already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company 312 ACTIVITY-EXERCISE PATTERN Home Maintenance, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient demonstrate alterations necessary to reduce impaired home maintenance? Yes No Record data, e.g., can return-demonstrate Reassess using initial assessment factors. with accuracy [list specific alterations here]. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can return- demonstrate [alteration] with Did evaluation show another difficulty. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company INFANT BEHAVIOR, DISORGANIZED, RISK FOR AND ACTUAL, AND READINESS FOR ENHANCED ORGANIZED 313 Infant Behavior, Disorganized, Risk for C. Readiness for Enhanced Organized Infant Behavior 1. Definite sleep-wake states and Actual, and Readiness for 2. Use of some self-regulatory behaviors Enhanced Organized 3. Response to visual or auditory stimuli 4. Stable physiologic measures DEFINITIONS21 RELATED FACTORS21 Risk for Disorganized Infant Behavior Risk for alteration and modulation of the physiologic and behavioral systems of function- A. Disorganized Infant Behavior ing, that is, autonomic, motor, state, organizational, self-regulatory, 1. Prenatal and attention-interaction systems. a. Congenital or genetic disorders b. Teratogenic exposure Disorganized Infant Behavior Disintegrated physiologic and 2. Postnatal neurologic responses to the environment. a. Malnutrition Readiness for Enhanced Organized Infant Behavior A pattern of b. Oral or motor problems modulation for the physiologic and behavioral systems of function- c. Pain ing, that is, autonomic, motor, state, organizational, self-regulatory, d. Feeding intolerance and attention-interaction systems, in an infant that is satisfactory but e. Invasive and/or painful procedures that can be improved, resulting in higher levels of integration in re- f. Prematurity sponse to environmental stimuli. 3. Individual a. Illness NANDA TAXONOMY: DOMAIN 9—COPING/STRESS b. Immature neurologic system TOLERANCE; CLASS 3—NEUROBEHAVIORAL STRESS c. Gestational age d. Postconceptual age NIC: DOMAIN 5—FAMILY; CLASS Z— 4. Environmental CHILDREARING CARE a. Physical environment inappropriateness b. Sensory overstimulation NOC: DOMAIN I—FUNCTIONAL HEALTH; c. Sensory deprivation CLASS B—GROWTH AND DEVELOPMENT 5. Caregiver a. Cue misreading DEFINING CHARACTERISTICS21 b. Cue knowledge deficit c. Environmental stimulation contribution A. Disorganized Infant Behavior B. Risk for Disorganized Infant Behavior 1. Regulatory problems The risk factors also serve as the related factors. a. Inability to inhibit C. Readiness for Enhanced Organized Infant Behavior b. Irritability 1. Pain 2. State-organization system 2. Prematurity a. Active awake (fussy, worried gaze) b. Diffuse or unclear sleep RELATED CLINICAL CONCERNS c. State oscillation d. Quiet-awake (staring, gaze aversion) 1. Hospitalization e. Irritable or panicky crying 2. Any invasive procedure 3. Attention-interaction system 3. Prematurity a. Abnormal response to sensory stimuli (e.g., difficult to 4. Neurologic disorders soothe, inability to sustain alert status) 5. Respiratory disorders 4. Motor system 6. Cardiovascular disorders a. Increased, decreased, or limp tone b. Finger splay, fisting, or hands to face c. Hyperextension of arms and legs HAVE YOU SELECTED d. Tremors, startles, and twitches THE CORRECT DIAGNOSIS? e. Jittery, jerky, or uncoordinated movement f. Altered primitive reflexes There are really no other diagnoses that can 5. Physiologic be confused with this one. Assessment will a. Bradycardia, tachycardia, or arrhythmias clearly show the difference between the b. Pale, cyanotic, mottled, or flushed color family diagnoses and this one. c. Bradypnea, tachypnea, or apnea d. “Time-out signals” (e.g., gaze, grasp, hiccough, cough, sneeze, sigh, slack jaw, open mouth,

tongue thrust) EXPECTED OUTCOME e. Oximeter desaturation Will return to more organized behavioral response by [date]. f. Feeding intolerances (aspiration or emesis) B. Risk for Disorganized Infant Behavior (Risk Factors) TARGET DATES 1. Invasive or painful procedures 2. Lack of containment or boundaries Disorganized infant behavior is very tiring, physically and emo- 3. Oral or motor problems tionally, to both the infant and parents. Therefore, the initial target 4. Prematurity date should be within 24 hours of the diagnosis. As the infant’s be- 5. Pain havior becomes more organized, target dates can be increased in in- 6. Environmental overstimulation crements of 72 hours. Copyright © 2002 F.A. Davis Company 314 ACTIVITY-EXERCISE PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this diagnosis, the Child Health nursing actions serve as the generic actions. This diagnosis would probably not arise on an adult health care unit. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributing factors related to the Inclusion of all contributing factors will result in an individualized infant’s status, including: plan of care. � Prenatal course � Birth history and Apgar scores � Known medical diagnoses � All genetically relevant data � Actual description of problem/triggering cues � Treatment modalities (monitors, medications, special equipment, and/or special care related) • Determine the mother’s and father’s (parental) perception of the Ultimate responsibility will better be assumed by the caregiver if infant’s status. planning is long term and considers parental input. • Identify specific parameters (according to etiologic or known Treatment of condition will be enhanced with a specific, cause of problem) for appropriate management of infant; i.e., individualized plan of care. Inclusion of early childhood laboratory ranges and respiratory rate (ABGs) or laboratory developmental specialist, occupational therapist, physical therapist, range as applicable. dietitian, home health nurse, and others as required will offer essential specialized care. • Evaluate parental capacity to assume caregiving role of the Anticipatory planning will enhance likelihood of adequate timing infant by: and gradual relinquishment of care to the parents or, when � Asking the parent to verbalize special care the infant requires necessary, other primary caregivers. � Observing the parent in care behaviors while still in hospital setting for appropriateness; e.g., feeding, handling, or as necessary, giving medications, suctioning, etc. � Assessing problem-solving skills related to the infant’s care; i.e., when to call for assistance � Risk factor analysis of total 24-h care of the infant � Ability to identify the infant’s cues � Ability to respond to the infant’s cues � Ability to handle, emotionally and otherwise, demands of the infant’s status � Verbalization of expected prognosis or developmental potential � Evidence of realistic planning for respite care backup after discharge from hospital • Provide anticipatory care, including positioning, in planning for Appropriate anticipation of possible cardiac or respiratory arrest feedings, if necessary, with safety-mindedness as dictated by the and/or related dysfunction of vital functions will best identify infant’s status, including possibility of cardiac or respiratory arrest. degree of physiologic support required to sustain the infant. • Provide stimulation only as tolerated by the infant, to include Protection of the infant from undue environmental stressors during minimal gentle touching, decreased sound, decreased light, acute phase will decrease the possibility of increased levels or lengh decreased strong chemical odors, and gentle suctioning of of time when disorganized behavior is present. oropharynx as necessary. • Support the infant in basic physiologic needs as required, Support of adaptive potentials may help restore patterns of including: organized behavior or at least maintain a more enhanced organized � Dietary needs (p.o., gastrostromy tube, hyperalimentation, etc.) behavior pattern with individualized allowances as a basis for � Respiratory functioning or maintenance (O2, tracheotomy, determining effective care. endotracheal
ventilation
pulmonary toileting) � Urinary/elimination (self-toileting, diapering, Foley catheter) � Cardiac homeostasis (self-regulatory, medication, pacemaker, monitoring) � Neuromuscular requisites (positioning in alignment, protection from injury in event of seizure, use of splints, special equipment for adaptive needs, administration of seizure medications if needed) (continued) Copyright © 2002 F.A. Davis Company INFANT BEHAVIOR, DISORGANIZED, RISK FOR AND ACTUAL, AND READINESS FOR ENHANCED ORGANIZED 315 (continued) ACTIONS/INTERVENTIONS RATIONALES � Communication augmentation (close and continuous observation, interpretation of cues, adaptive aids ranging from musical toys to developmentally appropriate interactive toys) � Tolerance of stimulation (satisfactory oxygen saturation, ability to rest at intervals, etc.) READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR • Monitor for all factors contributing to disorganized behavior that Inclusion of all contributing factors will most likely offer potential can be controlled, e.g., sounds, sights, and other stimuli. to influence the infant’s behavior on an individualized basis. • Develop a plan for identifying adaptation behaviors for evaluating Ongoing evaluation will serve the purpose of substantiation of effectiveness of current treatment and redefinition. progress and thereby define enhancement behaviors and patterns. • Once enhancement behaviors are able to be identified, redefine plan of care to best incorporate desired behaviors to degree possible. NOTE: Case management becomes an issue of paramount importance with a need to keep the family updated as changes occur. Also, in event of compromise and/or ultimate death, there should be con- sideration for: Spiritual Distress, Risk for Anticipatory Grieving Parent, Infant, Child Attachment, Impaired, Risk for all of which are related to the status of the infant. Also, it could be that this infant requires long-term care with allowance for acute exacerbations made worse by underlying disorganized infant behavior. Women’s Health NOTE: This diagnosis will relate to the delivery room and the immediate postpartum period (48 to 72 hours). For further clarification beyond this period, see Child Health. ACTIONS/INTERVENTIONS RATIONALES • Monitor the infant’s cardiovascular and respiratory system by Apgar score is an indicator of the infant’s condition at birth and use of Apgar score, at 1 and 5 min after birth. provides a baseline for determining the need for appropriate interventions and neonatal resuscitation. • Prepare for neonatal resuscitation by having all equipment and If there is a compromised infant, then it is appropriate for the nurse supplies ready. Be prepared to support neonatal staff, if available, in the delivery room to support and assist the neonatal staff in and/or pediatrician. Support and reassure the parents by keeping stabilizing the infant. If no neonatal staff is available, the labor- them informed of the infant’s condition. delivery staff need to be well versed in neonatal stabilization and resuscitation. • Support the parents of the ill neonate by being available to listen Parents often need to verbalize what they have been told by the and answer questions. neonatologist and the NICU staff. This helps them cope and can � Act as a liaison between neonatal intensive care unit (NICU) provide clarification of any information they have been given. The and the parents, assisting both parties by clarifying and nurse who listens can correct inaccurate perceptions and keep explaining. NICU staff informed of the parents’ understanding so they can � Accompany and/or transport the patient to NICU the first better understand and provide support where the mother and time, to provide guidance and support, as well as introducing family are physically and emotionally stressed. him or her to the NICU staff. � If the infant is transported to another hospital, keep the mother informed by establishing contact with the NICU staff. � Obtain pictures of the infant and telephone numbers so the mother can call and talk with NICU staff. • Monitor and document the infant’s physiologic parameters Utilizing every opportunity to teach new parents about their during periods of reactivity: newborn increases confidence and infant caretaking activities. � Assist new parents in utilizing the normal periods of reactivity in the neonate to begin breastfeeding and the parent-infant attachment process. � Perform a complete physical assessment of the newborn, documenting findings in an organized manner (usually head to toe). (continued) Copyright © 2002 F.A. Davis Company 316 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Note and inform the parents of aspects of normal newborn appearance, especially noting such items as milia, normal newborn rash, or “stork bites.” � Explain the importance of thermoregulation, voiding patterns, and neurologic adaptations during the immediate newborn period. � Practice good handwashing techniques before touching the newborn, and explain the importance of this to the parents in preventing infection. � Monitor the infant for ability to feed (breast or bottle), intake, output, and weight loss or gain. � Encourage parent participation in the care and observation of the infant. � Be available to answer questions and demonstrate techniques of baby care to new parents. • Prevent heat loss by immediately drying the infant and laying Drying decreases the incidence of iatrogenic hypothermia in the him or her on a warmed surface (best place is skin to skin with newborn. (Infant’s temperature can drop as much as 4.7F in the the mother). delivery room.82) IMMEDIATE POSTPARTUM PERIOD • Perform a gestational age assessment, and compare the infant’s Gestational age and the size (AGA, SGA, LGA) of the infant can gestational age and weight. Based upon this examination, affect the transition to extrauterine life. determine whether infant is83: � Average for gestational age (AGA) � Small for gestational age (SGA) � Large for gestational age (LGA) • Review the mother’s prenatal history and labor-delivery history The use of drugs during labor or prenatally and maternal diseases for factors that would interfere with the normal transitional such as diabetes may inhibit the thermoregulatory and physiologic process by the neonate, such as metabolic disorders cardiovascular responses or respiratory effort.83 (diabetes, etc.) and/or use of medications, both therapeutic and abusive. • Continue to monitor the infant’s vital signs frequently. Psychiatric Health NOTE: Mental health interventions for this diagnosis would focus on family support. Refer to the fol- lowing diagnoses for care plans: Management of Therapeutic Regimen (Family), Ineffective Caregiver Role Strain Family Coping, Compromised or Disabled Family Coping, Readiness for Enhanced Parenting, Impaired or Risk for The practitioner should review the definition and defining characteristics of these diagnoses to determine which one relates to those characteristics being demonstrated by the infant’s family and/or support system. Gerontic Health This diagnosis would probably not be used in gerontic health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in lifestyle changes that may be Home-based care requires involvement of the family. Disorganized required. Provide for: infant behavior can disrupt family schedules. Adjustment in family � Supportive environment activities may be required. � Consistent care provider � Appropriate stimulation � Control of pain � Understanding of normal growth and development • Assist the family to set criteria to help them determine when Provides the family with background knowledge to seek appropriate additional intervention is required, e.g., change in baseline assistance as need arises. physiologic measures. • Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the infant. Use of readily available resources is cost effective. Copyright © 2002 F.A. Davis Company INFANT BEHAVIOR, DISORGANIZED, RISK FOR AND ACTUAL, AND READINESS FOR ENHANCED ORGANIZED 317 Infant Behavior, Disorganized, Risk for and Actual, and Readiness for Enhanced Organized FLOWCHART EVALUATION: EXPECTED OUTCOME Has the infant returned to a more organized pattern of behavior? Yes No Record data, e.g., TPR and BP within Reassess using initial assessment factors. normal limits, sleeps 4–6 h with no problems, no tremors noted for 48 h. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., vital signs still varying from norm, sleep pattern Did evaluation show another very irregular, frequent tremors. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 318 ACTIVITY-EXERCISE PATTERN Peripheral Neurovascular Dysfunction, 3. Thrombophlebitis 4. Burns Risk for 5. Cerebrovascular accident DEFINITION A state in which an individual is at risk of experiencing a disrup- HAVE YOU SELECTED tion in circulation, sensation, or motion of an extremity.21 THE CORRECT DIAGNOSIS? NANDA TAXONOMY: DOMAIN 11—SAFETY/ Ineffective Tissue Perfusion Ineffective Tissue PROTECTION; CLASS 2—PHYSICAL INJURY Perfusion is an actual diagnosis and indicates that a definite problem has developed. Risk NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; for Peripheral Neurovascular Dysfunction CLASS A—ACTIVITY AND EXERCISE MANAGEMENT indicates that the patient is

in danger of NOC: DOMAIN II—PHYSIOLOGIC HEALTH; developing a problem if appropriate nursing CLASS E—CARDIOPULMONARY measures are not instituted to offset the problem development. DEFINING CHARACTERISTICS21 1. Trauma EXPECTED OUTCOME 2. Vascular obstruction 3. Orthopedic surgery Will develop no problems with peripheral neurovascular function 4. Fractures by [date]. 5. Burns 6. Mechanical compression, for example, tourniquet, cast, brace, TARGET DATES dressing, or restraint 7. Immobilization Initial target dates should be stated in hours. After the patient is able to be more involved in self-care and prevention, the target date can RELATED FACTORS21 be expressed in increments of 3 to 5 days. The risk factors also serve as the related factors for this risk diagnosis. RELATED CLINICAL CONCERNS 1. Fractures 2. Buerger’s disease NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to do ROM exercise every 2 h on [odd/even] Increases circulation and maintains muscle tone and movement. hour. • Instruct the patient regarding isometric and isotonic exercises. Increases circulation and maintains muscle tone. Have the patient exercise every 4 h while awake at [times]. • Collaborate with dietitian regarding a low-fat, low-cholesterol Maintains hydration and assists in preventing development of diet. Maintain fluid and electrolyte balance. atherosclerosis. • Complete traction checks and peripheral assessments every Helps monitor deviations from baseline before problem reaches a 2 h on [odd/even] hour. serious state. • Keep extremities warm. Promotes circulation. • Turn every 2 h on [odd/even] hour. Prevents sustained pressure on any pressure point. • Monitor skin integrity every 2 h on [odd/even] hour. Allows intervention before skin breakdown occurs. • Plan activity-rest schedule on a daily basis. Increases circulation and maintains muscle tone without fatiguing the patient. • Monitor the patient’s understanding of effect of smoking, or if Smoking constricts peripheral circulation, leading to increased nonsmoker, the effects of passive smoke on peripheral circulation. problems with peripheral neurologic and vascular functioning. Copyright © 2002 F.A. Davis Company PERIPHERAL NEUROVASCULAR DYSFUNCTION, RISK FOR 319 Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine exact parameters to be used in monitoring risk Specific parameters for assessment of neurodeficits can guide concerns, e.g., if the patient is without sensation in specific caregivers in choosing the best precautionary treatment. levels of anatomy, document what the known deficits are: High level of myelomeningocele, lumbar 4, with apparent sensation in peroneal site. • Carry out treatments with attention to the neurologic deficits, Common safety measure. e.g., using warm pads for a child unable to perceive heat would require constant attention for signs or symptoms of burns. • Provide teaching according to the patient and family needs, Appropriate assessment will best foster learning and help prevent especially with regard to safety. injury. • Include the family in care and use of equipment, e.g., braces, etc. Family involvement assuages the child’s emotional needs and empowers the parents. • Provide dismissal follow-up. Long-term follow-up validates the need for rechecking and offers a time to reassess progress in goal attainment or altered patterns. Women’s Health NOTE: Women are at risk for thrombosis in lower extremities during pregnancy and the early post- partum period. Because of decreased venous return from the legs, compression of large vessels sup- plying the legs during pregnancy and during pushing in the second stage of labor, patients need to be continuously assessed for this problem.84 ACTIONS/INTERVENTIONS RATIONALES • Closely monitor the patient at each visit and teach patient to Knowledge of the problem and its causative factors can assist in self-monitor size, shape, symmetry, color, edema, and planning and carrying out good health habits during pregnancy. varicosities in the legs. This knowledge can assist in preventing thrombotic complications during pregnancy. • Encourage the patient to walk daily during the pregnancy and to wear supportive hosiery. • Assist the patient to plan a day’s schedule during pregnancy that will allow her time to rest. The schedule should also include several times during the day for her to elevate her legs. • Encourage the patient to use a small stool when sitting, e.g., at desk to keep feet elevated and less compression on upper thighs and knees. • In the event thrombophlebitis develops: Basic assessment for early detection of complications. � Monitor legs for stiffness, pain, paleness, and swelling in the calf or thigh every 4 h around the clock. � Place the patient on strict bedrest with affected leg elevated. Basic safety measure to avoid dislodging of clots. • Provide analgesics as ordered for pain relief, and assess for effectiveness within 30 min of administration. • Place a bed cradle on the bed. Keeps pressure of bed linens off the affected leg. • Administer and monitor the effects of anticoagulant therapy as ordered. Collaborate with physician regarding the frequency of laboratory examinations to monitor clotting factors. NOTE: Breastfeeding mothers who are taking heparin can continue to breastfeed. Breastfeeding mothers who are taking dicumarol should stop breastfeeding, because it is passed to the infant in breast milk. • Do not rub, massage, or bump affected leg. Handle with care Basic safety measures to avoid dislodging clots. when changing linens or giving bath. • Assist the family to plan for care of the infant; include the Assist the patient and family in coping with illness. Promotes mother in planning process. effective implementation of home care. Provides support and teaching opportunity. • Encourage verbalizations of fears and discouragement by the mother and family. Copyright © 2002 F.A. Davis Company 320 ACTIVITY-EXERCISE PATTERN Psychiatric Health The mental health client with this diagnosis would require the same type of nursing care as the adult client. A review of the nursing actions for Activity Intolerance, Impaired Physical Mobility, and Ineffective Tis- sue Perfusion would also be of assistance. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Avoid the use of restraints if at all possible. Restraint use in older adults can lead to physical and mental deterioration, injury, and death.85 • Monitor restraints, if used, at least every 2 h on [odd/even] hour. Frequent monitoring decreases the injury risk. Release restraints, and perform ROM exercises before reapplying. Home Health Nursing actions for the home health client with this diagnosis would be the same as those for the adult health client. Copyright © 2002 F.A. Davis Company PERIPHERAL NEUROVASCULAR DYSFUNCTION, RISK FOR 321 Peripheral Neurovascular Dysfunction, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Reassess the patient’s neurovascular status. Are there any indications of neurovascular dysfunction? No Yes Record data, e.g., peripheral neurovascular Reassess using initial assessment factors. assessment within normal limits; assessment has been within normal limits for past 3 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has developed signs and symptoms of impaired Did evaluation show another circulation to lower left leg. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 322 ACTIVITY-EXERCISE PATTERN Physical Mobility, Impaired RELATED FACTORS21 DEFINITION 1. Medications 2. Prescribed movement restrictions A limitation in independent purposeful physical movement of the 3. Discomfort body on one or more extremities.*21 4. Lack of knowledge regarding value of physical activity 5. Body mass index above 75th age-appropriate percentile NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 6. Sensoriperceptual impairments CLASS 2—ACTIVITY/EXERCISE 7. Neuromuscular impairment 8. Pain NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 9. Musculoskeletal impairment CLASS A—ACTIVITY AND EXERCISE MANAGEMENT 10. Intolerance to activity or decreased strength and endurance NOC: DOMAIN I—FUNCTIONAL HEALTH; 11. Depressive mood state or anxiety CLASS C—MOBILITY 12. Cognitive impairment 13. Decreased muscle strength, control, and/or mass DEFINING CHARACTERISTICS21 14. Reluctance to initiate movement 15. Sedentary lifestyle or disuse or deconditioning 1. Postural instability during performance of routine activities of 16. Selective or generalized malnutrition daily living 17. Loss of integrity of bone structure 2. Limited ability to perform gross motor skills 18. Developmental delay 3. Limited ability to perform fine motor skills 19. Joint stiffness or contracture 4. Uncoordinated or jerky movements 20. Limited cardiovascular endurance 5. Limited range of motion 21. Altered cellular metabolism 6. Difficulty turning 22. Lack of physical or social environmental supports 7. Decreased reaction time 23. Cultural beliefs regarding age-appropriate activities 8. Movement-induced shortness of breath 9. Gait changes (e.g., decreased walk-spread, difficulty initiating RELATED CLINICAL CONCERNS gait, small steps, shuffles feet, exaggerated lateral position sway) 10. Engages in substitutions for movement (e.g., increased atten- 1. Fractures that require casting or traction tion to other’s activity, controlling behavior, focus on pre- 2. Rheumatoid arthritis illness or disability activity) 3. Cerebrovascular accident 11. Slowed movement 4. Depression 12. Movement-induced trauma 5. Any neuromuscular disorder HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Activity Intolerance This diagnosis implies that contraction and relaxation. Because oxygen is the individual is freely able to move but cannot transported and dispersed to the muscle tissue via endure or adapt to the increased energy or oxygen the cardiovascular system, it is only logical that the demands made by the movement or activity. respiratory and cardiovascular diagnoses could Impaired Physical Mobility indicates that an impact mobility. individual would be able to move independently if Imbalanced Nutrition, More or Less Than Body something were not limiting the motion. Requirements Nutritional deficit would indicate Impaired Physical Mobility This diagnosis also that the body is not receiving enough nutrients for needs to be differentiated from the respiratory its metabolic needs. Without adequate nutrition, (Impaired Gas Exchange and Ineffective Breathing the muscles cannot function appropriately. With Pattern) and cardiovascular (Decreased Cardiac More Than Body Requirements, mobility may be Output and Ineffective Tissue Perfusion) nursing impaired simply because of the excess weight. In diagnoses. Mobility depends on effective breathing someone who is grossly obese, range of motion is patterns and effective gas exchange between the limited, gait is altered, and coordination and tone lungs and the arterial blood supply. Muscles have are greatly reduced. to receive oxygen and get rid of carbon dioxide for *Suggested Functional Level Classification EXPECTED OUTCOME 0  Completely independent Will demonstrate increased strength and endurance by [date]. 1  Requires use of equipment or device 2  Requires help from another person, for assistance, supervision, or teaching TARGET DATES 3  Requires help from another person and equipment service 4  Dependent, does not participate in activity These dates may be short term or long term, based on the etiology Code adapted by NANDA from E. Jones, et al.: Patient Classification of the diagnosis. An acceptable first target date would be 5 days. for Long-Term Care Users’ Manual. HEW, Publication No. HRA-74-3107, November, 1974. Copyright © 2002 F.A. Davis Company PHYSICAL MOBILITY, IMPAIRED 323 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Maintain proper body alignment at all times; support extremities Prevents flexion contractures. with pillows, blankets, towel rolls, or sandbags. Use footboards, firm mattress, and bed boards as necessary to support positioning. • Implement measures to prevent falls, such as keeping bed in low Basic safety measures. position, raising siderails, and having items within easy reach. • Teach the patient how to move body in bed. Prevents shearing forces. Participation promotes self-esteem. • Perform ROM exercises (passive, active, and functional) every Increases circulation, maintains muscle tone, and prevents joint 2 h on [odd/even] hour. contractures. • Turn, cough, and deep breathe every 2 h on a schedule opposite Increases circulation, promotes maintenance of lung functioning, from the ROM exercises, e.g., if ROM on even hour, then turn, keeps airways clear, and assists in preventing hypostatic cough, and deep breathe on odd hour. Massage pressure points pneumonia. Improves tissue oxygenation. after turning. • Monitor skin over pressure areas every 4 h while awake at [times]. Basic monitoring of skin integrity. • Implement nursing actions specific to traction, casts, braces, Each of these therapies also has complicating side effects. prostheses, slings, and bandages. • Provide progressive mobilization as tolerated. Schedule increased Maintains muscle tone and prevents complications of immobility. mobilization on a daily basis, e.g., increase ambulation length by 25 ft each day. • Medicate for pain as needed, especially before activity. Document Pain interferes with ability to ambulate by inhibiting muscle effectiveness of medication within 30 min after administering movement. medication. • Apply heat or cold as ordered. Aids in muscle healing and promotes relaxation. • Maintain

adequate nutrition on a daily basis. Provides nutrients for energy, and prevents protein loss due to immobility. • Collaborate with physical therapist regarding exercise program. Coordinates team approach to care. • Observe for complications of immobility, e.g., negative nitrogen Allows early detection and prevention of complications. balance or constipation. • Provide health teaching: Facilitates understanding of care. Encourages participation in care. � Transfer methods Promotes effective management of therapeutic regimen. � Use of assistive devices � Safety precautions � Positioning and body mechanics � Prescribed exercise � Self-care activities • Include the patient and family or significant other in carrying Allows time for practice under supervision. Increases likelihood of out plan of care. effective management of therapeutic regimen. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor alteration in mobility each 8-h shift according to: Provides the primary database for an individualized plan of care. � Actual movement noted and tolerance for the movement � Factors related to movement, e.g., braces used, progress in use � Situational factors, e.g., previous status, current health needs, or movement permitted � Pain � Circulation check to affected limb � Change in appearance of affected limb or joint • Include related health team members in care of the patient as The nurse is in the prime position to coordinate health team needed. members to best match needs and resources. • Consider patient and family preferences in planning to meet Consideration of preferences increases likelihood of plan success. desired mobility goals. (continued) Copyright © 2002 F.A. Davis Company 324 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Encourage family members, especially the parents, to participate Involving the family in care serves to enhance their skills in care in care of the patient according to needs and situation (feeding, required at home. comfort measures). • Provide diversional activities appropriate for age and Diversional activity, when appropriately planned, serves to refresh developmental level. and relax the patient. • Maintain appropriate safety guidelines according to age and Basic requirements for maintaining standards of care. developmental guidelines. • Devote appropriate attention to traction or related equipment in Ensures therapeutic effectiveness of equipment, and provides for use, e.g., weights hanging free or rope knots tight. safety issues related to these interventions. • Monitor patient and family needs for education regarding the Allows timely planning for home care, and allows practice of care patient’s situation and any futuristic implications. in a supportive environment. • Attend to intake and output to ensure adequate fluid balance for Strict intake and output will assist in monitoring hydration status, each 24-h period. which is crucial for healing and circulatory adequacy. • Address related health issues appropriate for the patient and Appropriate attention to related health issues fosters holistic care; family. e.g., the child may need braces, but may also have need for healing, or speech follow-up secondary to meningitis, and developmental delays. Women’s Health NOTE: The following nursing actions apply to those women placed on restrictive activities because of threatened abortions, premature labor, multiple pregnancy, or pregnancy-induced hypertension. ACTIONS/INTERVENTIONS RATIONALES • Encourage the family and significant others to participate in plan of care for the patient. • When resting in bed, have the patient rest in left lateral position Prevents supine hypotension, and allows adequate renal and as much as possible. uterine perfusion. • Encourage the patient to list lifestyle adjustments that will need to be made. • Teach the patient relaxation skills and coping mechanisms. Decreases anxiety and muscle tension. • Encourage adequate protein intake. Replaces protein lost because of decreasing muscle contraction during immobility. • Maintain proper body alignment with use of positioning and pillow. • Provide diversionary activities, e.g., hobbies, job-related activities Decreases anxiety and reduces muscle tension. Provides appropriate that can be done in bed, or activities with children. amounts of activity without danger to pregnancy. • Encourage help and visits from friends and relatives: � Visit in person � Telephone visit � Help with child care � Help with housework Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES NOTE: The following actions and interventions are related to imposed restrictions. This includes seclusion and restraint. • Attempt all other interventions before considering immobilizing Promotes the client’s sense of control and supports self-esteem. the client as an intervention (see Risk for Violence, Chap. 9, for appropriate nursing actions). . • Carefully monitor the client for appropriate level of restraint necessary. Immobilize the client as little as possible while still protecting the client and others. • Obtain necessary medical orders to initiate methods that limit the client’s physical mobility. (continued) Copyright © 2002 F.A. Davis Company PHYSICAL MOBILITY, IMPAIRED 325 (continued) ACTIONS/INTERVENTIONS RATIONALES • Carefully explain to the client in brief, concise language reasons Excessive stimuli can increase confusion. Provides the client with for initiating this intervention and what behavior must be sense of control. present for the intervention to be terminated. • Attempt to gain the client’s voluntary compliance with the Promotes the client’s sense of control and safety, which promotes intervention by explaining to the client what is needed and self-esteem. with a “show of force” (have the necessary number of staff available to force compliance). • Initiate forced compliance only if there is an adequate number Client and staff safety are of primary concern. of staff to complete the action safely. (See Risk for Violence, Chap. 9, for a detailed description of intervention with forced compliance.) • Secure the environment the client will be in by removing Prevents injury by protecting the client from impulsive actions of harmful objects such as accessible light bulbs, sharp objects, self-harm. glass objects, tight clothing, and metal objects such as clothes hangers or shower curtain rods. • If the client is placed in four-point restraints, maintain Client safety is of primary concern. one-to-one supervision. • If the client is in seclusion or in bilateral restraints, observe the client at least every 15 min, more frequently if agitated (list observation schedule here). • Leave urinal in room with the client, or offer toileting every hour. • Offer the client fluids every 15 min. Maintains adequate hydration. • Discuss with the client his or her feelings about the initiation of Exploration of feelings in an accepting environment helps the client immobility, and review with him or her again, at least twice a identify and explore maladaptive coping behaviors. Promotes the day, the behavior necessary to have immobility discontinued. client’s sense of perceived control. • When checking the client, let him or her know you are checking Promotes perceived control and promotes an environment of trust. by calling him or her by name and orienting him or her to day and time. Inquire about the client’s feelings, and implement necessary reality orientation. • Provide meals at regular intervals on paper containers, providing Meet biophysical need while providing consistency in a respectful necessary assistance (amount and type of assistance required manner, which promotes self-esteem and trust. should be listed here). • If the client is in restraints, remove restraints at least every 2 h, Promotes normal circulation and motion, which prevents injury to one limb at a time. Have the client move limb through a full the limb. ROM and inspect for signs of injury. Apply lubricants such as lotion to area under restraint to protect from injury. • Pad the area of the restraint that is next to the skin with Protects skin from mechanical irritation. sheepskin or other nonirritating material. • Check circulation in restrained limbs in the area below the Early assessment and intervention prevents serious injury. restraint by observing skin color, warmth, and swelling. Restraint should not interfere with circulation. • Change the client’s position in the bed every 2 h on [odd/even] Prevents disuse syndrome. hour. • Place body in proper alignment. Use pillows for support if the Prevents complications and injury. client’s condition allows. • If the client is in four-point restraints, place him or her on Prevents aspiration or choking. stomach or side. • Place the client on intake and output monitoring. Ensures that adequate fluid balance is maintained. • Have the client in seclusion move around the room at least every Prevents complications of immobility. 2 h on [odd/even] hour, and during this time initiate active ROM. • Administer medications as ordered for agitation. Medications reduce anxiety and facilitate interaction with others. • Monitor blood pressure before administering antipsychotic Psychotropic medications can cause orthostatic hypotension. medications. • Assist the client with daily personal hygiene (record time for Communicates positive regard for the client by the nurse, which this here). facilitates the development of positive self-esteem. • Have environment cleaned on a daily basis. Promotes sanitary conditions and provides an orderly environment, which can decrease the client’s disorganization and confusion. • Review with the client the purpose for restraint or seclusion as Promotes the client’s sense of control by providing him or her with required, and discuss alternative kinds of behavior that will behavioral alternatives and establishing clear limits. express feelings without threatening self or others. (continued) Copyright © 2002 F.A. Davis Company 326 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Remove the client from seclusion as soon as the contracted Provides positive reinforcement for appropriate coping behavior, behavior is observed for the required amount of time (both of and promotes the client’s sense of control. these should be very specific and listed here). (See Risk for Violence, Chap. 9, for detailed information on behavior change and contracting specifics.) � Schedule time to discuss this intervention with the client and Support system understanding and support of treatment goals has his or her support system. Inform support system of the need a positive effect on client outcome. for the intervention and about special considerations related to visiting with the client. This information must be provided with consideration of client confidentiality. Plan to spend at least 5 min with the members of the support system before and after each visit. � Arrange consultations with appropriate resources after the client Facilitates the development of trust as well as respect for the client, is released from mobility limitations to assist the client with which can have a positive effect on the client’s self-esteem. developing alternative coping behavior. This could include a physical therapist, an occupational therapist, or a social worker. NOTE: The following interventions are related to restrictions due to psychogenic causes. � If restrictions are due to anxiety, refer to Chapter 8 and the diagnosis of Anxiety. � If restrictions are due to depressed mood, implement the following interventions: (1) Sit with the client for [number] minutes [number] times per shift. Initially these times will be brief but frequent, e.g., 5 min per hour. (2) Establish clear expectations for these interactions, e.g., Communicates respect for the client, and facilitates the client’s the client is not expected to talk, it is ok for these times perception of control. to be spent in silence. • Explain to the client in simple concrete terms the positive effects Physical activity can stimulate endorphin production, which has a of physical activity on mood. Note person responsible for this positive effect on mood. teaching here. • Talk with the client about activities they have enjoyed in the past. Promotes a positive expectational set based on past positive experiences. • Develop with the client program for increasing physical activity. Promotes the client’s sense of control. Positive reinforcement Note that contact here. Also note rewards for accomplishing encourages behavior and enhances self-esteem. goals, e.g., will walk from bed to door once per hour. If accomplished, the client can remain in bed during visiting hours. Activities can increase as the client masters each step. • Provide positive verbal reinforcement for accomplishing tasks. Positive recognition from significant others enhances self-esteem. • Recognize the client’s perceptions about the difficulty of physical Communicates acceptance of the client, and facilitates the activity in the initial stages of recovery. development of a trusting relationship. • Pair physical activity with situations the client finds rewarding. Promotes positive expectational set by pairing physical exercise Note these situations here, e.g., walking with the client to get a with a positive stimulus. cup of coffee. This pairs walking with two things the client finds rewarding: (1) time with nurse and (2) coffee. • Have the client identify perceived barriers to increased physical Promotes the client’s sense of control, and increases the client’s activity. Note those here and develop with the

client plan for commitment to the plan because he or she has contributed to the reducing these. Note plan here. plan. • Teach support system importance of the client’s increasing Support system involvement increases the probability for positive physical activity, and have them identify ways they could assist outcome. with this. Note here the person responsible for this, and record the plan when it is developed. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for complications of immobility such as: Normal aging changes in combination with immobility can leave � Orthostatic hypotension the older adult at increased risk for complications.86 (continued) Copyright © 2002 F.A. Davis Company PHYSICAL MOBILITY, IMPAIRED 327 (continued) ACTIONS/INTERVENTIONS RATIONALES � Thrombosis � Urinary tract infections � Constipation • Observe the patient for Valsalva maneuver (increased Valsalva maneuver can produce increased pulse rate and increased intrathoracic pressure induced by forceful exhalation against a blood pressure. This adversely affects patients with cardiovascular closed glottis) when he or she is changing position, pushing a disorders, which may lead to their choosing not to engage in wheelchair, or toileting. physical activity.86 • Monitor for behavioral changes that may result from decreased Psychological changes not addressed may increase problems of sensory stimulation or decreased socialization, e.g., depression, physical mobility and lead to prolonged periods of immobility. hostility, confusion, or anxiety. • Observe when increasing mobility, transferring, or during early Older adults may be at risk for fall secondary to orthostatic blood ambulation stage for the risk for falls. pressure changes or problems with balance, especially after prolonged periods of immobility. • Teach the client to perform isometric muscle contraction, i.e., Isometric contraction helps maintain muscle strength, which can tightening of muscle group as hard as possible and then relaxing decrease with immobility as much as 5 percent per day.86 the muscle. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient and family in identifying risk factors pertinent Locus of control shifts from nurse to the client and family, thus to the situation: promoting self-care. � Immobility � Malnourishment � Confusion or lethargy � Physical barriers � Neuromuscular deficit � Musculoskeletal deficit � Trauma � Pain � Medications that affect coordination and level of arousal � Debilitating disease (cancer, stroke, diabetes, muscular dystrophy, multiple sclerosis, arthritis, etc.) � Depression � Lack of or improper use of assistive devices � Casts, slings, traction, IVs, etc. � Weather hazards • Teach the client and family measures to promote physical activity: � Use of assistive devices (wheelchairs, crutches, canes, walkers, prostheses, adaptive eating utensils, devices to assist with activities of daily living, etc.) � Providing safe environment (reducing barriers to activity such as throw rugs, furniture in pathway, electric cords on floor, doors, or steps) � Maintaining skin integrity � Use of safety devices (ramps, lift bars, tub rails, tub or shower seat) � Proper transfer techniques • Assist the patient and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Alteration in living space (ramps, assistive devices, etc.) � Changes in role functions � Range of motion exercises � Positioning and transferring techniques � Pain control � Progressive activity � Use of assistive devices � Prevention of injury � Maintenance of skin integrity (continued) Copyright © 2002 F.A. Davis Company 328 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Assistance with activities of daily living � Special transportation needs � Financial concerns • Consult with or refer the patient to appropriate assistive Provides additional support for the client and family, and uses resources as indicated. already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company PHYSICAL MOBILITY, IMPAIRED 329 Physical Mobility, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Does the patient report, and do your observations validate, increased strength and endurance? Yes No Record data, e.g., handles walker much Reassess using initial assessment factors. easier now; has doubled distance can walk. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., reported, “Crutch walking very tiring”; still ambulating Did evaluation show another only 150 ft at a time. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 330 ACTIVITY-EXERCISE PATTERN Self-Care Deficit (Feeding, Bathing-Hygiene, D. Toileting Self-Care Deficit 1. Inability to manipulate clothing Dressing-Grooming, Toileting) 2. Unable to carry out proper toilet hygiene 3. Unable to sit or rise from toilet or commode DEFINITION 4. Unable to flush toilet or commode An impaired ability to perform or complete feeding, bathing- hygiene, dressing-grooming, or toileting activities for oneself.21 RELATED FACTORS21 A. Feeding Self-Care Deficit NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 1. Weakness or tiredness CLASS 2—ACTIVITY/EXERCISE 2. Severe anxiety NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 3. Neuromuscular impairment CLASS F—SELF-CARE FACILITATION 4. Pain 5. Perceptual or cognitive impairment NOC: DOMAIN I—FUNCTIONAL HEALTH; 6. Discomfort CLASS D—SELF-CARE 7. Environmental barriers 8. Decreased or lack of motivation DEFINING CHARACTERISTICS21 9. Musculoskeletal impairment B. Bathing-Hygiene Self-Care Deficit A. Feeding Self-Care Deficit 1. Decreased or lack of motivation 1. Inability to swallow food 2. Weakness or tiredness 2. Inability to prepare food for ingestion 3. Severe anxiety 3. Inability to handle utensils 4. Inability to perceive body part or spatial relationship 4. Inability to chew food 5. Perceptual or cognitive impairment 5. Inability to use assistive devices 6. Pain 6. Inability to get food onto utensil 7. Neuromuscular impairment 7. Inability to open containers 8. Musculoskeletal impairment 8. Inability to manipulate food in mouth 9. Environmental barriers 9. Inability to ingest food safely C. Dressing-Grooming Self-Care Deficit 10. Inability to bring food from a receptacle to the mouth 1. Decreased or lack of motivation 11. Inability to complete a meal 2. Pain 12. Inability to ingest food in a socially acceptable manner 3. Severe anxiety 13. Inability to pick up cup or glass 4. Perceptual or cognitive impairment 14. Inability to ingest sufficient food 5. Neuromuscular impairment B. Bathing-Hygiene Self-Care Deficit 6. Musculoskeletal impairment 1. Inability to get bath supplies 7. Discomfort 2. Inability to wash body or body parts 8. Environmental barriers 3. Inability to obtain or get to water source 9. Weakness or tiredness 4. Inability to regulate temperature or flow of bath water D. Toileting Self-Care Deficit 5. Inability to get in and out of bathroom 1. Environmental barriers 6. Inability to dry body 2. Weakness or tiredness C. Dressing-Grooming Self-Care Deficit 3. Decreased or lack of motivation 1. Inability to choose clothing 4. Severe anxiety 2. Inability to use assistive devices 5. Impaired mobility status 3. Inability to use zippers 6. Impaired transfer ability 4. Inability to remove clothes 7. Muscloskeletal impairment 5. Inability to put on socks 8. Neuromuscular impairment 6. Inability to put clothing on upper body 9. Pain 7. Impaired ability to put on or take off necessary items of 10. Perceptual or cognitive impairment clothing 8. Impaired ability to obtain or replace articles of clothing RELATED CLINICAL CONCERNS 9. Inability to maintain appearance at a satisfactory level 10. Inability to put clothing on lower body 1. Cerebrovascular accident 11. Inability to pick up clothing 2. Spinal cord injury 12. Inability to put on shoes 3. Dementia 4. Depression 5. Rheumatoid arthritis Copyright © 2002 F.A. Davis Company SELF-CARE DEFICIT (FEEDING, BATHING-HYGIENE, DRESSING-GROOMING, TOILETING) 331 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Activity Intolerance This diagnosis implies that Most likely, Self-Care Deficit would be a the individual is freely able to move but cannot companion diagnosis. endure or adapt to the increased energy or oxygen Ineffective Individual Coping or Compromised or demands made by the movement or activity. Disabled Family Coping Suspect one of these Activity Intolerance can be a contributing factor to diagnosis if there are major differences between the development of self-care deficits. reports by the patient and the family of health Impaired Physical Mobility This diagnosis is quite status, health perception, and health care often a contributing factor to the development of behavior. Verbalizations by the patient or the Self-Care Deficit. It is probable that any time a family regarding inability to cope also require patient has Impaired Physical Mobility, he or looking at these diagnoses. she will also have some degree of Self-Care Interrupted Family Processes Through observing Deficit. family interactions and communication, the nurse Disturbed Thought Process If the patient is may assess that Interrupted Family Processes exhibiting impaired attention span; impaired should be considered. Poorly communicated ability to recall information; impaired perception, messages, rigidity of family functions and roles, judgment, and decision making; or impaired and failure to accomplish expected family conceptual and reasoning ability, the most proper developmental tasks are a few observations to alert diagnosis would be Disturbed Thought Process. the nurse to this possible diagnosis. EXPECTED OUTCOME TARGET DATES Will return-demonstrate, with 100 percent accuracy, [specify] self- Overcoming a self-care deficit will take a significant investment of care by [date]. time; however, 7 days from the date of diagnosis would be appro- priate to check for progress. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: Self-care deficits range from a total self-care deficit to very specific areas of self-care deficits, such as bathing-hygiene or feeding. The nursing actions presented are general in nature and would need to be adapted to fit the exact self-care deficit of the individual. Collaboration with a rehabilita- tion nurse clinician and/or review of rehabilitation literature would be excellent sources for current and specific nursing actions related to a patient’s particular self-care deficit. Review of the nursing ac- tions for Urinary Incontinence, Activity Intolerance, Impaired Physical Mobility, Impaired Skin In- tegrity, and Imbalanced Nutrition will also be helpful. ACTIONS/INTERVENTIONS RATIONALES • Provide extra time for giving daily care, and include: Instills trust, avoids overwhelming the patient, facilitates � Emotional support self-motivation, and allows immediate feedback on self-care. � Teaching � Return-demonstration of self-care activities • Provide privacy and safety for the patient to practice self-care. Avoids embarrassment for the patient, provides basic safety, and allows practice under closely supervised situation. • Remind the patient to wear corrective appliances, e.g., braces, Promotes self-care by offsetting present limitations. dentures, eyeglasses, or hearing aid. • Provide positive reinforcement for each self-care accomplishment. Increases self-esteem and motivation. • Perform ROM exercises, or assist the patient with every 4 h Increases circulation and maintains muscle tone and joint mobility. while awake at [times]. • Assist the patient and significant others in planning measures to Promotes timely home care planning and encourages participation overcome or adapt to self-care deficits: in care. � Gradual increments in self-care responsibility, e.g., getting up in chair independently before ambulating to bathroom by self � Self-care assistive devices, e.g., helping hand (continued) Copyright © 2002 F.A. Davis Company 332 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist significant others to provide assistive devices, e.g., raised toilet seat, buttonhook, or angled extension comb and brush. • Place visual aid in room to help document progress: Visually documents success. � Chart that allows placement of stars for each day the patient accomplishes goal in self-care � Calendar to document progress • Monitor: Baseline data needed to validate progress and assist in determining � Vital signs every 4 h while awake at [times] physiologic impact of progress. � Ambulation: Increase, to extent possible, on a daily basis • Collaborate with physician regarding pain management. Pain inhibits muscle movement and activity. • Measure intake and output. Total every 8 h and every 24 h. Basic monitoring of fluid and electrolyte status that impacts mobility and self-care. • Monitor bowel elimination at least once daily at [time]. Baseline data that assist in determining bowel functioning pattern. • Establish bowel- and bladder-retraining programs as necessary. Provides basic education, practice, and reinforcement that facilitates (See Bowel Incontinence and Urinary Incontinence, Chap. 4.) the patient’s control of these functions. • Collaborate with dietitian regarding diet, e.g., foods to facilitate Promotes self-care, and provides motivation to continue striving self-feeding. for improvement. • Refer the patient to community support services. Provides for long-term support. • Have visiting nurse service assist significant others to adapt Provides time to adapt home for basic safety measures. home environment, at least 3 days prior to discharge: � Nonskid

rugs � Ramps � Handrails � Safety strips in tub and shower Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the patient’s and parents’ potential for self-care Provides a database for an individualized plan of care. measures appropriate to age and developmental factors. • Allow the patient and parents to participate in planning for care Enhances satisfaction, and increases likelihood that care will be when possible to help ensure best compliance. continued after discharge from hospital. • Teach the appropriate skills necessary for self-care in the child’s Individualized teaching best affords reinforcement of learning. terms, with sensitivity to developmental needs for practice, Sensitivity to special need attaches value to the patient and family’s repetition, or reluctance. needs. • Provide opportunities that will enhance the child’s confidence Confidence in self-care will enhance self-esteem. in performing self-care. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to list lifestyle adjustments that need to Promotes gradual assumption of self-care while avoiding be made. overwhelming the patient with activities that must be accomplished. • Encourage progressive activity and increased self-care as tolerated: � Ambulation � Bathing � Body image and early postpartum exercises � Bowel care � Breast care � Perineal care • Encourage the patient to get adequate rest: � Take care of self and baby only. � Let significant other take care of the housework and other children. � Learn to sleep when the baby sleeps. � Have specific, set times for friends or relatives to visit. (continued) Copyright © 2002 F.A. Davis Company SELF-CARE DEFICIT (FEEDING, BATHING-HYGIENE, DRESSING-GROOMING, TOILETING) 333 (continued) ACTIONS/INTERVENTIONS RATIONALES � If breastfeeding, significant other can bring the infant to the mother at night (the mother doesn’t have to get up every time for the infant). • Provide quiet, supportive atmosphere for interaction with the Promotes attachment. infant. • Instruct the patient in infant care, and have her return-demonstrate: Basic teaching measures for care of newborn. � Bathing (1) Never leave the infant or small child alone in bath. (2) Bathe the infant in small area (kitchen sink is good) for first weeks. (3) Use warm area in house. (4) Use area convenient for the mother. (5) Be sure area is not drafty. (6) Never run water directly from faucet onto the infant, always test with forearm before placing the infant in water (water should be warm, but not too hot). � Cord care (1) Clean cord with alcohol and cotton swabs when changing diapers. (2) Clean around base of cord. (3) Leave cord alone until it drops off. (4) Alert the mother that there will be a small amount of spotting (bleeding) at cord site when it drops off. � Clothing (1) To determine whether the infant is warm enough, feel the infant’s chest or back with hand; never judge the infant’s body temperature by feeling the infant’s hands or feet. (2) Use mild detergent when laundering the infant’s clothing � Diapering (1) Cloth diapers (2) Disposable diapers (3) Cleaning of the infant when changing diapers � Circumcision care—Yellen clamp (metal clamp) (1) Gently wash penis with water to remove urine and feces. (2) Reapply fresh, sterile Vaseline gauze around glans. (3) It is best to use cloth diapers until completely healed (approximately 7–10 days). � Circumcision care—plastic bell (1) Gently wash penis with water to remove urine and feces. (2) Do not apply petrolatum gauze. (3) Leave plastic circle on penis alone until tissue heals and circle falls off. � Taking the baby’s temperature and reading a thermometer: (1) Axillary (2) Rectal • Explain infant alert and rest states and how the caretaker can Promotes attachment. best use these states to interact with the infant. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Determine the client’s optimum level of functioning and note here. This information assists in establishing realistic goals. • Develop behavioral short-term goals by: Goal accomplishment provides positive reinforcement and � Listing those activities the client can assume enhances self-esteem. � Breaking these activities into their component parts � Determining how much of each activity the client could successfully complete, and listing achievable activities here with goal achievement dates � Discussing expectations with the client (continued) Copyright © 2002 F.A. Davis Company 334 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Keep instructions simple. Inappropriate levels of sensory stimuli can contribute to the client’s sense of disorganization and confusion. • Provide support to the client during tasks by: Interaction with the nurse can be a source of positive reinforcement. � Spending time with the client while he or she is completing the task. � Having all items necessary to achieve task readily available. Increases possibility for the client to successfully complete the task. � Assisting the client in focusing on the task at hand. � Providing positive verbal feedback as each step of the task is Positive feedback encourages behavior. achieved. • Keep environment uncluttered, presenting only those items Inappropriate levels of sensory stimuli can contribute to the client’s necessary to complete the task in the order needed. sense of disorganization and confusion. • Develop a reward schedule for achievement of goals. Discuss Promotes the client’s sense of control. Positive feedback encourages with the client possible rewards, and list those things the client behavior. finds rewarding here with the goal to be achieved to gain the reward. • Schedule adequate time for the client to accomplish task Communicates acceptance of the client, which facilitates the (depressed client may need 2 h to bathe and dress). development of trust and self-esteem. • Decrease environmental stimuli to the degree necessary to assist Promotes the client’s sense of control. the client in focusing on task. • Present activities of daily living on a regular schedule and note that schedule here. This schedule should be developed in consultation with the client. • Spend [number] minutes with the client twice a day discussing Expression of feelings in a safe environment can facilitate problem feelings and reactions to current progress and expectations. identification and the development of coping strategies. Times for this and person responsible for this activity should be listed here. • Allow the client to perform activities even though it might be Communicates trust, and promotes the client’s sense of control. easier at times for staff to complete the task for the client. • Communicate expectations and goals to all staff members. Promotes consistency in the treatment, and communicates respect for the client. • Discuss with the family and other support systems and the Increases potential for success of treatment plan. client the plan and goals. Spend at least 5 min with the family after each visit to answer questions and explain treatment plan. • Have members of support system identify how they can assist the client in achieving established goals. • Spend time with the client discussing alternative ways of coping Promotes the client’s sense of control when encountering these with the frustration that may occur while attempting to reach difficulties. Successful coping will promote positive self-esteem. established goals. • Collaborate with occupational therapist or physical therapist regarding special adaptations needed to assist the client with task accomplishment, e.g., exercises to increase muscle strength when muscles have not been used for a period of time. • Monitor effects medications might have on goal achievement, and collaborate with physician regarding problematic areas. • Develop goals and schedules with the client, communicating that he or she does have responsibility and control in issues related to care. • Discuss with the client and significant others those things that Facilitates the development of positive coping strategies, and will facilitate continuance of self-care at home, and develop a increases potential for success when the client returns home. plan that will assist the client in obtaining necessary items. Successful accomplishment of this transition promotes positive self-esteem. • Refer to community resources as necessary for continued support. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Teach self-monitoring skills such as maintaining a journal or Encourages the patient to identify areas that may need improvement diary to record what factors may increase the self-care deficit. or changes in lifestyle.87 • Contract with the patient for achievement of specific Enhances motivation to increase self-care. incremental goals, and provide rewards or reinforcements when goals are met. Copyright © 2002 F.A. Davis Company SELF-CARE DEFICIT (FEEDING, BATHING-HYGIENE, DRESSING-GROOMING, TOILETING) 335 Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor factors contributing to self-care deficit of [specify]. Provides database for prevention and/or early intervention. This includes items in the related factors section. • Involve the client and family in planning, implementing, and Involvement improves motivation and improves the outcome. promoting reduction of the specific self-care deficit: � Family conference � Mutual goal setting � Communication • Assist the client and family to obtain assistive equipment as Assistive equipment improves function and increases the required: possibilities for self-care. � Raised toilet seat � Adaptive equipment for eating utensils, combs, brushes, etc. � Rocker knife � Suction device under plate or bowl � Wrist or hand splints � Blender, crockpot, or microwave � Long-handled reacher (helping hand) � Box on seat of chair � Raised ledge on utility board � Straw and straw holder � Washcloth with soap � Wheelchair, walker, motorized cart, or cane � Bedside commode, incontinence undergarments � Bars and attachments and benches for shower or tub � Hand-held shower device � Long-handled sponge � Shaver holder � Medication organizers and magnifying glass � Diet supplements � Hearing aid � Corrective lenses � Dressing aids: dressing stick, zipper pull, buttonhook, long-handled shoehorn, shoe fasteners, or Velcro closures • Teach the client and family signs and symptoms of Planning activities around physical capabilities prevents further overexertion: reduction in self-care capacity. � Pain � Fatigue � Confusion � Decrease or excessive increase in vital signs � Injury • Assist the client and family in lifestyle adjustments that may be Provides basic information for the client and family that promotes required: necessary lifestyle changes. � Proper use of assistive equipment � Adapting to need for assistance or assistive equipment � Determining criteria for monitoring client’s ability to function unassisted � Time management � Stress management � Development of support systems � Learning new skills � Work, family, social, and personal goals and priorities � Coping with disability or dependency � Providing environment conducive to self-care privacy, pain relief, social contact, and familiar and favorite surroundings and foods � Prevention of injury (falls, aspiration, burns, etc.) � Monitoring of skin integrity � Development of consistent routine � Mechanism for alerting family members to need for assistance • Refer the patient to appropriate assistive resources as indicated. Provides additional support for the client and family, and uses already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company 336 ACTIVITY-EXERCISE PATTERN Self-Care Deficit (Feeding, Bathing-Hygiene, Dressing-Grooming, Toileting) FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate with 100% accuracy self-care in specified areas? Yes No Record data, e.g., can perform self- Reassess using initial assessment factors. toileting accurately and consistently; no problems reported by the patient or observed over past 2 wk. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can perform self-bathing but is having problems Did evaluation show another with self-toileting; has difficulty problem had arisen? Yes transferring from wheelchair to toilet seat and in maintaining a regular schedule. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SPONTANEOUS VENTILATION, IMPAIRED 337 Spontaneous Ventilation, Impaired 4. Increased restlessness 5. Increased heart rate DEFINITION 6. Decreased tidal volume 7. Decreased pO2 A state in which the response pattern of decreased energy reserves 8. Decreased cooperation results in an individual’s inability to maintain breathing adequate 9. Apprehension to support life.21 10. Decreased SaO2 11. Increased use of accessory muscles NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; CLASS 4—CARDIOVASCULAR/PULMONARY RELATED FACTORS21 RESPONSE 1. Respiratory muscle fatigue NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 2. Metabolic factors CLASS K—RESPIRATORY MANAGEMENT NOC: DOMAIN II—PHYSIOLOGIC HEALTH; RELATED CLINICAL CONCERNS CLASS E—CARDIOPULMONARY 1. Chronic obstructive pulmonary disease (COPD) DEFINING CHARACTERISTICS21 2. Asthma 3. Closed head injury 1. Dyspnea 4. Respiratory arrest 2. Increased metabolic rate 5. Cardiac surgery 3. Increased pCO2 6. Adult respiratory distress syndrome (ARDS) HAVE YOU SELECTED

THE CORRECT DIAGNOSIS? Ineffective Breathing Pattern In this diagnosis, Impaired Gas Exchange This diagnosis refers to the patient’s respiratory effort is insufficient to the exchange of oxygen and carbon dioxide in the maintain the cellular oxygen supply. Both lungs or at the cellular level. Both this diagnosis diagnoses would contribute to the patient’s being and Impaired Spontaneous Ventilation placed on ventilatory assistance; however, demonstrate this characteristic, but Impaired Impaired Spontaneous Ventilation would be a Spontaneous Ventilation is of a more critical more life-threatening, critical diagnosis than just an nature than an impairment. Ineffective Breathing Pattern. The major difference would be the criticalness of the patient’s condition. EXPECTED OUTCOME TARGET DATES Blood gases will return to normal range by [date]. Because of the life-threatening potential of this diagnosis, initial tar- get dates will need to be stated in terms of hours. After the patient’s condition has improved and stabilized, the target date can be in- creased in increments of 1 to 3 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor negative pressure (pneumobelt or pneumowrap) or Ensures correct functioning of equipment. positive pressure (intermittent or continuous) ventilators at least hourly. • Continuously monitor the patient’s response to ventilator. Fear of ventilator malfunction can alter respiratory efforts. • Provide sedation if needed. Prevents the patient from working against (“bucking”) the ventilator. • Verify ventilator settings every hour. Ensures adequate functioning of equipment. • Schedule at least 15 min every hour to talk with the patient. Decreases anxiety, and helps prevent the patient from working against the ventilator. (continued) Copyright © 2002 F.A. Davis Company 338 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Reassure the patient’s family while the patient is on ventilator. • Monitor vital signs, especially respiratory status, at least every Essential monitoring of respiratory and ventilator effectiveness. hour and every time nurse is with the patient. • Collaborate with physician regarding frequency of ABG Monitors effectiveness of therapy. measurements. • Use pulse oximeter to determine oxygen saturation, and monitor every 15–30 min. • Elevate head of bed 30 degrees if not contraindicated. Facilitates diaphragmatic excursion. • Suction as needed. Removes secretions that may block airways. • Observe closely for oxygen toxicity. Inappropriate functioning of ventilator can cause greater oxygen consumption than the body can tolerate. • Turn every 2 h on [odd/even] hour. Facilitates lung expansion, helps mobilize secretions, improves circulation to extremities, and prevents pressure ulcers. • Explain all procedures and manipulations of ventilator to the Assists in reducing anxiety. patient prior to implementing. Keep call light within reach. • Provide alternative methods of communication, e.g., magic slate, pad and pencil, or flash cards of usual requests (bedpan, urinal, pain, etc.) • Provide adequate hydration. Monitor and document intake and Avoids fluid-volume deficit, assists in liquefying secretions, and output at least every shift, total every 24 h. Weigh the patient prevents development of pulmonary edema. daily at same time and in same-weight clothing. • Monitor for respiratory function, e.g., temperature, culture, and Infection increases the respiratory demand and increases secretions. sensitivity of respiratory secretions. It will also decrease gas exchange. • Provide chest physiotherapy and postural drainage if not Loosens and mobilizes secretions. contraindicated. • Plan activity-rest schedule on a daily basis. Allow at least 2 h of Conserves energy and promotes REM (rapid eye movement) sleep. uninterrupted rest during the day. • Review the patient’s resources and support systems for Initiates timely home care planning. management of ventilator at home. • Collaborate with respiratory therapists as needed. Ensures coordination of care. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine parameters for respiratory status: A specific respiratory assessment will help individualize the need � Range of acceptable rate, rhythm, and quality of respiration plan of care. � Limits for apnea monitor setting.88 The settings should be set for a range of safety according to age-related norms: (1) Neonates: 30–60 (2) Infants: 25–60 (3) Toddlers: 24–40 (4) Preschoolers: 22–34 (5) Adolescents: 12–16 � Arterial blood gases � Oxygen saturation levels � Respiratory testing, e.g., pneumogram � Other indicators of respiratory function, e.g., cyanosis, mottling, diminished pulses, listless behavior, poor feeding, or vital signs • Provide one-to-one care for infants and children at risk for In high-risk respiratory patients, the possibility of arrest should be apnea or pulmonary arrest. planned for. Identification of the actual arrest is a major factor in successful resuscitation. • Keep emergency medications and equipment (Ambu bag, Success in appropriate treatment of pulmonary arrest requires airway, suctioning equipment, crash cart, ventilator, and oxygen) anticipatory planning with standard treatment modalities according in close proximity. to the American Heart Association guidelines and Pediatric Advanced Life Support guidelines. • Administer medication as ordered, being careful in administration Anticipatory planning for the possibility of respiratory depression of medications that might affect respirations, e.g., narcotics, or arrest will lessen the likelihood of actuality in many instances bronchodilators, or vasoconstrictors. Monitor blood levels for and serve to allow for more success in treatment of these problems. (continued) Copyright © 2002 F.A. Davis Company SPONTANEOUS VENTILATION, IMPAIRED 339 (continued) ACTIONS/INTERVENTIONS RATIONALES therapeutic parameters of aminophylline-theophylline. Report If neuromuscular blocking agents are utilized, exercise caution in levels above or below the desired range. positioning because of the possibility of dislocation.71 • Encourage the family to ventilate concerns about the patient’s Verbalization of concerns helps reduce anxiety and provides respiratory status. subjective data for assessment and an opportunity for teaching. • Allow parental input as an option when it is realistic. Parental involvement provides emotional security for the child and reinforces parental coping. • Carry out teaching according to inquiries by the patient or family. Individualized learning is facilitated when it is directed toward stated needs. • Check level of consciousness (responsiveness) at least every Decreased responsiveness is indicative of onset of respiratory failure. 30 min. • Monitor and document episodes of crying that result in apnea Breath-holding or crying may seem to cause hypoxia, but often or loss of usual color for prolonged periods (15 s or more). there are underlying causes. Attention to underlying cause can be carried out, but vigilance for possible arrest is necessary. • Exercise caution in feeding or offering fluids. Possible aspiration is likely if the infant is apneic, unable to suck well, or has problems swallowing. • Monitor for contributing factors to problem: Alteration in any aspect of respiratory anatomy will affect adequate � Central nervous system status ventilation. � Airway � Chest wall � Respiratory muscles � Lung tissue ADDITIONAL INFORMATION: In the event of a decision to withhold or cease use of the ventilator for the purpose of determining brain death, be aware of the major nursing implications involved in legal acts related to brain death determination in children. Women’s Health The nursing actions for Women’s Health are the same as those for Adult Health. Psychiatric Health NOTE: If the client develops this diagnosis while being cared for in a mental health unit, he or she should immediately be transferred to an intensive care unit or adult health unit. A mental health unit is not equipped to handle this type of emergency. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for iatrogenic reactions to medications. Medication reactions may decrease respiratory drive and effort. • Observe for signs and symptoms of sleep-pattern disturbance. Decreased rest secondary to sleep-pattern disturbances further diminishes physiologic reserves in older patients.89 Home Health NOTE: Should the home health client develop this diagnosis, the nurse should immediately have the client transferred to an acute care setting for the proper care. Copyright © 2002 F.A. Davis Company 340 ACTIVITY-EXERCISE PATTERN Spontaneous Ventilation, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Review blood gas reports for the past 72 h. Have blood gases returned to and remained in the normal ranges during this period of time? Yes No Record data, e.g., all blood gas reports Reassess using initial assessment factors. have remained within normal limits for past 72 h; presents no defining characteristics of diagnosis. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., blood gas reports still demonstrate decreased pO2 and Did evaluation show another increased pCO2. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 341 Tissue Perfusion, Ineffective (Specify Type: j. Bruits k. Delayed healing Renal, Cerebral, Cardiopulmonary, l. Diminished arterial pulsations Gastrointestinal, Peripheral) m. Skin color pale on elevation, color does not return on lower- ing leg DEFINITION RELATED FACTORS21 A decrease in oxygen resulting in failure to nourish the tissues at the capillary level.21 1. Hypovolemia 2. Interruption of arterial flow NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; 3. Hypervolemia CLASS 4—CARDIOVASCULAR/PULMONARY 4. Interruption of venous flow RESPONSE 5. Mechanical reduction of venous and/or arterial blood flow 6. Hypoventilation NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; 7. Impaired transport of oxygen across alveolar and/or capillary CLASS N—TISSUE PERFUSION MANAGEMENT membrane NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 8. Mismatch of ventilation with blood flow CLASS E—CARDIOPULMONARY 9. Decreased hemoglobin concentration in blood 10. Enzyme poisoning 11. Altered affinity of hemoglobin for oxygen DEFINING CHARACTERISTICS21 1. Renal RELATED CLINICAL CONCERNS a. Altered blood pressure outside of acceptable parameters b. Hematuria 1. Thrombophlebitis c. Oliguria or anuria 2. Amputation reattachment d. Elevation in blood urea nitrogen (BUN) and/or creatinine ratio 3. Varicosities 2. Cerebral 4. Diabetes mellitus a. Speech abnormalities 5. Cardiac infections b. Changes in pupillary reactions 6. Anemia c. Extremity weakness or paralysis 7. Myocardial infarction d. Altered mental status 8. Coronary artery disease e. Difficulty in swallowing 9. Kawasaki’s disease f. Changes in motor response 10. Congestive heart failure g. Behavioral changes 11. Congenital cardiac anomalies 3. Cardiopulmonary 12. Coronary artery aneurysm a. Altered respiratory rate outside of acceptable parameters b. Use of accessory muscles c. Capillary refill greater than 3 seconds HAVE YOU SELECTED d. Abnormal arterial blood gases e. Chest pain THE CORRECT DIAGNOSIS? f. Sense of “impending doom” Decreased Cardiac Output Ineffective g. Bronchospasms Tissue Perfusion relates to deficits in the h. Dyspnea peripheral circulation with cellular impact. i. Arrhythmias Decreased Cardiac Output relates j. Nasal flaring specifically to a heart malfunction. Tissue k. Chest retraction perfusion problems may develop secondary 4. Gastrointestinal to decreased cardiac output but can also a. Hypoactive or absent bowel sounds exist without cardiac output problems.59 b. Nausea c. Abdominal distention d. Abdominal pain or tenderness 5. Peripheral EXPECTED OUTCOME a. Edema b. Positive Homans’ sign Will have no signs or symptoms of Ineffective Tissue Perfusion by c. Altered skin characteristics (hair, nails, and moisture) [date]. d. Weak or absent pulses e. Skin discoloration TARGET DATES f. Skin temperature changes g. Altered sensations A maximum target date would be 2 days from the date of admis- h. Claudication sion because of the dangers involved. A patient who develops this i. Blood pressure changes in extremities diagnosis should be referred to a medical practitioner immediately. Copyright © 2002 F.A. Davis Company 342 ACTIVITY-EXERCISE PATTERN ADDITIONAL INFORMATION water, oxygen, nutrients, and hormones to the cells and to remove carbon dioxide, waste products, and heat from the cells. The size of Perfusion is the movement of blood to and from a body part. Ade- the blood vessels decreases along the length of the arterial system, quate perfusion determines cell survival and depends on an adequate which increases resistance to fluid flow. To perfuse the cells ade- pump and vascular volume as well as adequate functioning of the quately, the mean arterial blood pressure is maintained within a rel- precapillary sphincters. The adequacy of these structures is affected atively narrow range by such regulatory systems as the barorecep- by, among others, vasomotor, metabolic, and neural factors.60,90 tors, sympathetic nerves, and the cardiac branch of the vagus The basic function of the cardiovascular system is to transport nerve.60,90 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor, initially every 2 h on [odd/even] hour, then increasing Determines changes in physiologic baselines. Permits early detection to every 4 h at [times]: and treatment of complications. � Peripheral pulses � Capillary refill � Skin temperature � Edema: Measure circumference (abdomen and ankles) with tape measure � Motor and sensory status � Vital

signs � For signs and symptoms of pulmonary edema • Weigh daily at 7 a.m. Allows monitoring of fluid balance. • Measure intake and output. Total every 8 and 24 h. • Monitor bowel elimination at least daily. Permits assessment of nutritional status and bowel functioning. • Position the patient carefully, and change position at least every Promotes circulation. Prevents pressure ulcers and prevents venous hour while awake: stasis. � Arterial interference: Head and chest elevated, and extremities in dependent position. � Venous interference: Extremities elevated. � Combined arterial-venous interference: Supine. � Apply sheepskin, alternating air mattress, or egg crate mattress to bed. � Provide heel and elbow protectors. � Provide bed cradle to avoid linen pressure on extremities. � Do not use knee gatch or pillows under knees. • Provide skin and foot care at least once per shift at [times]: Prevents skin integrity problems. � Cleanse and dry well. � Apply lotion. � Do not massage if possibility of emboli exists. • Collaborate with enterostomal therapist regarding care of open lesions: � Cleansing � Medicated ointments, etc. � Dressings • Exercise extremities at least every 4 h while awake at [times]: Facilitates circulation and assists in preventing complications of � ROM immobility. � Buerger-Allen exercises • Collaborate with physical therapist regarding gradually increasing total exercise program. • Apply supportive or antiembolic hose. Remove for at least 30 Promotes venous return. Avoids skin integrity problems. min each shift at [times], and cleanse skin underneath. • Collaborate with physician regarding frequency of each of the Allows determination of any changes in physiologic indicators of following laboratory examinations, and monitor results: tissue perfusion. � Electrolytes � Arterial blood gases � Blood urea nitrogen � Cardiac enzymes � Coagulation time (continued) Copyright © 2002 F.A. Davis Company TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 343 (continued) ACTIONS/INTERVENTIONS RATIONALES • Administer, as ordered, and monitor results of medications: Basic monitoring of the various drugs used in the variety of � Analgesics situations related to ineffective tissue perfusion. � Anticoagulants � Vasodilators � Antilipemics • Apply, and monitor closely, warm packs for phlebitis. Promotes venous return and awareness of possibility of burn injury. • Collaborate with dietitian regarding dietary adaptations: Nutritional changes that may assist in avoiding future episodes of � Calorie restrictions tissue perfusion alterations. � Lowered cholesterol � Decreased saturated fats � Decreased caffeine and alcohol intake • Teach the patient and assist in implementation at least once Decreases anxiety and modifies sympathetic nervous system per shift while awake at [times]: response. � Stress management techniques � Relaxation techniques • Teach the patient and significant others: Basic home care planning. Promotes participation in care and � Exercise program implementation of prescribed regimen. � Dietary adaptations � Smoking cessation � Avoidance of extremes in temperature � Avoidance of prolonged standing, sitting, or crossing of legs � Avoidance of over-the-counter medications � Continued use of stress management and relaxation techniques � Skin and foot care � Prescribed medication regimen: Effects and toxicity • Refer to visiting nurse service. Provides long-term support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Perform appropriate monitoring and documentation for Provides basic database to ascertain progress and to individualize contributory factors to include: plan of care. � Circulatory monitoring of anatomic site or general signs and symptoms related to peripheral pulses � Apical pulse, blood pressure, temperature, and respiration (monitor at least every hour or as ordered, and check cardiac monitor if applicable) � Intake and output every hour � Nausea or vomiting � Constipation or diarrhea � Tolerance of feeding � Pain or discomfort � Skin color and temperature; any integrity problems � Circulatory pattern: Notify physician for any change in the pattern that suggests lack of oxygenation, e.g., cyanosis, arterial blood gas results, or decreased pulses. � Appropriate functioning of equipment, such as ventilator, arterial line, or intravenous pump � Maintenance of intravenous line for administration of fluids � Positional demands � Pain or discomfort � Sensory input appropriate for age and developmental status � Fluid and electrolytes • Collaborate with other health care providers as needed. Coordination and implementation of plan of care may involve numerous professionals according to the cause of alteration and the treatment modalities available. • Provide for appropriate availability of resuscitative equipment Basic emergency preparedness. including: � Ambu bag (continued) Copyright © 2002 F.A. Davis Company 344 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Crash cart for pediatrics with drugs and defibrillator � Appropriate respiratory intubation equipment • Allow for parental and child health teaching needs by allowing Verbalization of health-related concerns may serve as cues for 10–15 min per 8-h shift for verbalization of concerns. teaching needs and also serves to reduce anxiety. • Allow for parental participation in care of the child at Parental involvement in care puts the child at ease and provides appropriate level, e.g., giving comfort measures or assisting self-esteem and empowerment for the parents. with feeding. • Encourage rest by scheduling procedures together with ample Appropriate attention to rest needs helps prevent further metabolic time between activities. demands on already less than ideal homeostasis scenario. • Allow patient and parental preferences in plan of care. Individualization shows value attached to parents’ input. • Deal with appropriate related factors associated with ineffective All efforts to lessen workload on heart and respiratory system will tissue perfusion, e.g., minimizing crying by anticipating needs. assist in preventing further decompensation. • Provide appropriate safety for age, e.g., keeping siderails up or Safety is a standard part of care and ought to be planned for positioning as ordered. according to health status, age, and development. • Maintain proper use of equipment, such as Clinitron bed or Assists circulation. special K-pads. • Provide for appropriate follow-up via scheduled appointments Encourages consistency in long-range care. Demonstrates how to after hospitalization. schedule appointments, and provides support for parents. • Provide the patient with teaching appropriate to needs of illness Assists in reducing anxiety, and facilitates home management of care. and family, e.g., if activities and daily care are to be modified, consider use of pulse oximeter to monitor perfusion and explain how to do circulatory checks after cast application. • Ensure that the parents have been certified in CPR before the Basic need for home care when perfusion problem is present. child is dismissed from hospital. NOTE: A major effort will be that of follow-up with appropriate specialized care to include pediatric cardiology and, as needed, other expertise to anticipate a long course of therapy. Every aim is directed at early diagnosis, especially in instances of any congenital cardiac anomaly, e.g., simple coronary artery malformation versus that associated with other related physiologic malformation of the heart and vasculature. A specific concern is Kawasaki’s disease, with a residual concern of coronary artery aneurysm. Periodic echocardiography is mandated for those individuals. Women’s Health NOTE: In instances of decreased coronary tissue perfusion, the women’s health client should imme- diately be transferred to a coronary care unit. ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying lifestyle adjustments that may Decreases factors that could lead to decreased perfusion of oxygen be needed because of changes in physiologic function or needs to uterus, placenta, and fetus. during experiential phases of life (e.g., pregnancy, birth, and post partum and related to gynecology): � Avoid prolonged sitting, sitting with crossed legs, or standing. � Develop exercise plan for cardiovascular fitness during pregnancy. � Avoid wearing constrictive clothing. � Maintain a balanced diet with adequate hydration. � Avoid constipation and bearing down to prevent hemorrhoids. • Monitor the patient for signs of pregnancy-induced hypertension Allows early intervention to avoid perfusion problems and (PIH): development of complications. � Prenatal weight � Blood pressure � Presence of edema � Proteinuria � Preeclampsia � Headaches (continued) Copyright © 2002 F.A. Davis Company TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 345 (continued) ACTIONS/INTERVENTIONS RATIONALES � Visual changes such as blurred vision � Increased edema of face and pitting edema of extremities � Oliguria � Hyperreflexia � Nausea or vomiting � Epigastric pain � Eclampsia � Convulsions � Coma • Monitor for edema: Provides early warning of perfusion problems, and promotes early � Swelling of hands, face, legs, or feet. intervention. � Caution: Patient may have to remove rings. � May need to wear loose shoes or a bigger shoe size. � Schedule rest breaks during day when the patient can elevate legs. � When lying down, lie on left side to promote placental perfusion and prevent compression of vena cava. • In collaboration with physician (as appropriate), monitor: � Check intake and output (urinary output not less than 30 mL/h or 120 mL/4 h). � Use magnesium sulfate (MgSO4) and hydralazine hydrochloride (Apresoline) therapy according to physician order. Have antidote for MgSO4 (calcium gluconate) available at all times during MgSO4 therapy. � Assess deep tendon reflexes (DTR). � Check respiratory rate, pulse, and blood pressure at least every 2 h on [odd/even] hour. � Evaluate for possibility of seizures. � Limit the amount of noise in the patient’s environment. � Monitor fetal heart rate and well-being. • Provide quiet, nonstimulating environment for the patient. Reduces anxiety and promotes rest. Both measures will assist in maintaining peripheral circulation by avoiding vasoconstriction. • Provide the patient and family factual information and support Reduces anxiety and provides teaching opportunity. as needed. • Monitor and teach the patient to monitor and report any signs Allows early detection of problem and more rapid intervention. of PIH immediately: � Rapid rise in blood pressure � Rapid weight gain � Marked hyperreflexia, especially transient or sustained ankle clonus � Severe headache � Visual disturbances � Epigastric pain � Increase in proteinuria � Oliguria, with urine output of less than 30 mL/h � Drowsiness • In collaboration with dietitian: Dietary measures that assist in controlling blood pressure. � Obtain nutritional history. � Provide high-protein diet (80–100 g of protein). � Provide low-sodium diet (not more than 6 g daily or less than 2.5 g daily). ORAL CONTRACEPTIVE THERAPY • Monitor for factors that contraindicate use of oral birth control These factors promote side effects and untoward effects from birth pills: control pills. � Family history of stroke, diabetes, or reproductive cancer � History of thromboembolic disease or vascular problems, hypertension, hepatic disease, and smoking � Presence of any breast disease, nodule, or fibrocystic disease Copyright © 2002 F.A. Davis Company 346 ACTIVITY-EXERCISE PATTERN Psychiatric Health NOTE: The nursing actions in this section reflect alteration in tissue perfusion related to the cerebral and peripheral vascular systems, because these are the systems most commonly affected in the mental health setting. ACTIONS/INTERVENTIONS RATIONALES • Check on orthostatic hypotension by taking blood pressure Psychotropic medications can predispose the client to orthostatic while the client is lying down, then taking blood pressure just hypotension. after the client stands or sits up (provide support for the client to prevent injury from a fall). • Monitor the client’s mental status. If compromised, provide information in a clear, concise manner. • Discuss with the client causes of decreased cerebral blood flow. Assists in explaining reasons for therapies to the client. • Have the client get out of bed slowly by: Allows time for cardiovascular system to adapt, thus preventing � Sitting up fainting or dizziness due to orthostatic hypotension. � Swinging legs over edge of bed � Resting in this position for at least 2 min � Standing up slowly � Walking slowly • Teach the client to avoid situations in which he or she changes position quickly, e.g., bending over to pick something up off the floor or standing quickly from a sitting position. • Have the client supported while changing positions that cause vertigo until problem is resolved. • Assist the client in getting in and out of the bathtub. • Collaborate with physician regarding alterations in medications. Promotes changing to a medication that would not interfere with perfusion. • If situation persists, have the client: Provides external support for venous system. � Sleep sitting up or with head elevated. � Use elastic stockings that are waist high. � Apply stockings while the client is still in bed. � Have the client raise legs for several minutes. � Apply stockings slowly and evenly. � Remove stockings after the client is lying down at least every 8 h. •

Develop with the client a plan for daily exercise that is very Improves cardiovascular strength. Assists in maintaining muscle modest, e.g., walking the length of the hall for 15 min twice a tone, which assists in supporting the venous circulation. day for 3 days, then increasing distance and time gradually until the client is walking for 30 min twice a day. [Note the client’s exercise regimen here.] • Develop with the client a reward schedule for implementing exercise plan. [List rewards and the reward schedule here.] • Provide the client with positive verbal support for goal accomplishment. • Do not allow the client to participate in unit activities that could Basic safety measures. produce injury until the condition is resolved, e.g., cooking or using sharp objects while standing. • Discuss with the client the effects of alcohol and smoking on blood flow, and assist him or her to develop alternative coping behavior if necessary. [Note plan for this here.] • Provide decaffeinated beverages for the client. Consult with dietary department about this adaptation. • Increase the client’s fluid intake during times of increased loss, such as exercise or periods of anxiety. Instruct the client in the need for this. • Observe the client carefully after injecting medications that have Basic measure to offset the possibility of falling secondary to a high potential for producing hypotension. This is especially orthostatic hypotension. true for those clients who are very agitated and physically active. • Inform the client of need to change position slowly after injecting medication. • Teach the client and support system about over-the-counter medications that alter blood flow, e.g., cold medications, antihistamines, or diet pills. (continued) Copyright © 2002 F.A. Davis Company TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 347 (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor peripheral pulses on affected limbs every 8 h at [times]. • Avoid, and teach the client to avoid, pressure in points on Avoids compromising circulation by pressure or constriction. affected limbs to include: � Changing position frequently when sitting or lying down � Avoiding pressure in the area behind the knee � Not crossing legs while sitting � Making sure shoes fit properly and do not rub feet � Elevating feet when sitting to reduce pressure on backs of legs • Keep feet clean and dry, and teach the client to do same by Avoids lower extremity skin integrity problems and possible assessing foot condition once a day at [time]. This assessment infection with the resultant impact on circulation. should include: � Washing feet � Checking for sores, reddened areas, and blisters � Keeping toenails trimmed and caring for ingrown nails � Applying lotion to feet � Rubbing reddened areas if the client does not have a history of emboli � Applying clean, dry socks � Teaching significant others to assist with foot care of elderly client � Keeping limbs warm (but do not use external heating sources such as heating pads or hot-water bottles) • Develop with the client an exercise program, and note that Promotes normal venous return. program here. Begin slowly, and gradually increase time and distance, e.g., walk for 15 min 2 times per day for 1 wk. This should be increased until client is walking 1 mi in 30–45 min 3 times a week. • Instruct the client to discontinue exercise if: Client safety is of primary importance. � Pulse does not return to resting rate within 3 min after exercise. � Shortness of breath continues for more than 10 min after stopping exercise. � Fatigue is excessive. � Muscles are painful. � Client experiences dizziness, pain in the chest, lightheadedness, loss of muscle control, or nausea. • Encourage the client’s exercise by: � Walking with him or her � Determining things that the client would find rewarding and supplying these as goals are achieved � Providing positive verbal support as goals are achieved [Note the client’s specific reward system here.] • Monitor the client’s nutritional status, and refer to nutritionist for teaching if necessary. • Discuss with the client the effects of smoking on peripheral blood Nicotine causes vasospasm and vasoconstriction. flow, and assist him or her in decreasing or eliminating this by: � Referring the client to a stop-smoking group � Encouraging him or her not to smoke before meals or exercise � Decreasing amount smoked per day • Discuss special needs with the client and support system before Increases probability of the client’s behavior change being discharge. maintained after discharge. • Refer the client to community agencies to provide ongoing care as needed. Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those for adult health and home health patients. ACTIONS/INTERVENTIONS RATIONALES • Monitor for signs of dyspnea, chronic fatigue, behavioral Older clients with decreased cardiac perfusion often present changes, or evidence of acute cerebral insufficiency. with these symptoms. (continued) Copyright © 2002 F.A. Davis Company 348 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Plan physical activities, such as hygiene, meals, and ambulation, Decreases cardiac workload. with rest periods. • Instruct in use of oxygen, if prescribed. Supplemental oxygen may be prescribed to help decrease cardiac workload. • Teach the client relaxation methods to help decrease anxiety. Decreasing anxiety helps decrease the release of catecholamines. An increase in catecholamines results in increased cardiac workload. Home Health NOTE: If this diagnosis is suspected when caring for a client in the home, it is imperative that a physi- cian referral be obtained immediately. If a physician has referred the client to home health care, the nurse will collaborate with the physician in the treatment of the client. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides database for prevention and/or early intervention. symptoms of alteration in tissue perfusion: � Pulse (lying, sitting, and standing) � Skin temperature and turgor � Edema � Motor status � Sensory status � Blood pressure (lying, sitting, standing, and pulse pressure) � Respiratory status (dyspnea, cyanosis, and rate) � Weight fluctuations � Urinary output � Leg pain with walking • Assist the client and family in identifying lifestyle changes that Provides basic information for the client and family that promotes may be required: necessary lifestyle changes. � Eliminating smoking � Decreasing caffeine � Decreasing alcohol � Avoiding over-the-counter medications � Protecting skin and extremities from injury due to decreased sensation (burns, frostbite, etc.) � Protecting skin from pressure injury (making frequent position changes and using sheepskin for pressure areas and foot cradle) � Improving arterial blood flow (keeping extremities warm, elevating head and chest, avoiding crossing legs or sitting for long periods of time, wiggling fingers and toes every hour, and performing ROM exercises) � Performing exercise program as tolerated � Improving venous blood flow (elevating extremity, using antiembolus stockings, and avoiding pressure behind knees) � Performing skin and foot care � Decreasing cholesterol and saturated fat intake � Performing diversional activities as needed � Practicing stress management • Teach the family basic CPR. • Teach the client and family purposes, side effects, and proper administration technique of medications. • Assist the client and family to set criteria to help them determine Locus of control shifts from nurse to the client and family, thus when a physician or other intervention is required. promoting self-care. • Consult with or refer to appropriate assistive resources as Provides additional support for the client and family, and uses indicated. already available resources in a cost-effective manner. Copyright © 2002 F.A. Davis Company TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 349 Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient exhibit or describe any signs or symptoms of Ineffective Tissue Perfusion? Yes No Reassess using initial assessment factors. Record data, e.g., carotid and temporal pulses easily palpated—strong and regular. No difficulty with vertigo. No mental confusion. Record RESOLVED (may wish to use CONTINUE until the patient is Is diagnosis validated? discharged from your service). Delete nursing diagnosis, expected outcome, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., leg peripheral pulses difficult to palpate; slow capillary refill in toenails; feet cold Yes No and slightly cyanotic; 3
pedal edema. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company 350 ACTIVITY-EXERCISE PATTERN Transfer Ability, Impaired 3. Impaired ability to transfer in and out of tub or shower 4. Impaired ability to transfer between uneven levels DEFINITION 5. Impaired ability to transfer from chair to car or car to chair 6. Impaired ability to transfer from chair to floor or floor to chair Limitation of independent movement between two nearby surfaces.21 7. Impaired ability to transfer from standing to floor or floor to standing NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; CLASS 2—ACTIVITY/EXERCISE RELATED FACTORS21 NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; To be developed. CLASS A—ACTIVITY AND EXERCISE MANAGEMENT AND CLASS C—IMMOBILITY MANAGEMENT RELATED CLINICAL CONCERNS NOC: DOMAIN I—FUNCTIONAL HEALTH; CLASS C—MOBILITY 1. Arthritis 2. Paralysis 3. Neuromuscular diseases DEFINING CHARACTERISTICS21 4. Amputation 5. Fractures 1. Impaired ability to transfer from bed to chair and chair to bed 2. Impaired ability to transfer on or off a toilet or commode HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Impaired Physical Mobility Certainly anyone who Ineffective Management of Therapeutic Regimen, had Impaired Transfer Ability would also have Individual A patient who cannot transfer himself Impaired Physical Mobility. The inability to or herself from one site to another could well have transfer from one site to another would need difficulty with managing a therapeutic regimen. to be resolved before Impaired Physical Mobility However, the patient will never be able to manage could be resolved. the therapeutic regimen until the problem with transfer ability is resolved. EXPECTED OUTCOME TARGET DATES Will independently transfer self by [date]. Resolving this diagnosis requires an extended length of time. An ap- propriate initial evaluation date would be 7 to 10 days after the date the diagnosis is made. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Apply a gait belt prior to attempting any sitting or standing Helps stabilize the patient and provide safety. transfer, particularly during the early stages of rehabilitation. TRANSFER FROM THE WHEELCHAIR TO THE BED • Position the wheelchair parallel or at a slight angle to the bed The patient should learn to transfer by leading with both the midway between the head and foot of the bed. Lock the weaker and the stronger extremities to increase his or her wheelchair with the caster wheels directed forward. independence and to encourage use of the weaker extremities.51 • Remove the patient’s feet from the footrests, and elevate the footrests. • Remove or swing away the front rigging, and place the patient’s feet flat on the floor. • If the top of the bed is lower than the armrest, remove the armrest. • Move the patient forward in the chair by grasping the posterior pelvis and pulling on it so that the buttocks slide forward, and position his or her feet parallel to each other. (continued) Copyright © 2002 F.A. Davis Company TRANSFER ABILITY, IMPAIRIED 351 (continued) ACTIONS/INTERVENTIONS RATIONALES • Partially stoop and position your knees and feet outside and touching the patient’s knees and feet. • If the patient is able, he or she can hold your middle or upper back with the upper extremities. • Grasp the gait belt at the sides of the patient’s waist and inform him or her when and how the move to standing is performed. If necessary, you may rock the patient to develop momentum prior to standing the patient. • Instruct the patient using terms such as “Ready, stand” or “1, 2, 3, stand.” • As you lift on the gait belt, simultaneously straighten your lower Allows the patient to stand briefly to establish balance and to extremities and stabilize the patient’s knees as he or she stands. determine whether he or she experiences lightheadedness or dizziness.51 • Elevate the body high enough to clear the wheelchair wheel, and stand the patient to the height necessary to elevate the pelvis above the level of the surface

of the bed. • Pivot yourself and the patient toward the bed and lower him or her onto the surface when his or her buttocks are turned so that they are directed toward the bed. • Set the patient on the edge of the bed, and then assist him or her to a supine position by lifting the lower extremities onto the bed.51 TRANSFER FROM THE BED TO THE WHEELCHAIR • The wheelchair should be positioned and locked as previously described. • Instruct or assist the patient to rise to a sitting position. • Instruct or assist the patient to move the hips to the edge of the bed and to place the feet on the floor in the position described previously. Stabilize one or both knees as the patient stands. • Instruct or assist the patient to push to a standing position and to reach for the near armrest of the wheelchair. • Instruct or assist the patient to pivot, reach for the far armrest, Caution: For patients with a recent total hip replacement, care must and continue pivoting until his or her back is toward the chair. be taken to avoid (1) adduction of the surgically replaced hip beyond a midline position, (2) excessive internal or external hip rotation, and (3) excessive hip flexion, which is usually restricted to 60 to 90 degrees. Thus, the patient must not pivot on that extremity when standing, flex the surgically replaced hip or his or her trunk excessively, or adduct the hip at any time during the transfer.51 • Instruct or assist the patient to lower the buttocks into the chair. • Reposition the front riggings and the footrests. • Place the patient’s feet on the footrests, and move the hips back into the chair seat.51 TRANSFER FROM THE WHEELCHAIR TO TOILET • Position the wheelchair and riggings as previously described. Safety. • Stand in front of the patient, flex your hips and knees, and Patient safety. Protects your back. position your knees and feet on the outside but next to the patient’s knees and feet. • Lift his or her thighs and hold them between your knees or lower thighs so that the patient’s feet are off the floor. • Flex the patient’s trunk with his or her head positioned on the side of your hip that is on the side opposite the direction of the transfer; the patient’s arms should be folded in the lap or across the chest. • Grasp the gait belt on each side of the patient, and lift him or Patient safety. Maintains control of the patient. her from the chair. • Pivot your body and turn the patient’s buttocks toward the toilet. • Lower the patient onto the toilet, place the feet on the floor, and straighten him or her to an upright sitting position. (continued) Copyright © 2002 F.A. Davis Company 352 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Be certain to protect the patient while sitting and reposition as necessary. • The return to the wheelchair is performed using the same techniques in reverse order.51 TRANSFER FROM WHEELCHAIR TO FLOOR NOTE: The specific techniques for transferring from a wheelchair to the floor and returning to the wheelchair vary according to the patient’s condition. For example, (1) if the patient has strong right upper and lower extremities and weak left upper and lower extremities (or strong left upper and lower extremities and weak right upper and lower extremities) or (2) strong upper extremities and weak or paralyzed lower extremities. Situation 1 • Instruct the patient to position the caster wheels forward, lock Patient safety. the chair, remove his or her feet from the footrests, and remove or swing away the front rigging or elevate the footrests. • Have the patient move forward in the chair with the body pivoted or turned slightly so that the strong extremities are most forward. • Instruct or assist the patient to shift his or her weight onto the strong lower extremity and to reach toward the floor with the strong upper extremity. • When the strong upper extremity is on the floor, the patient uses the strong upper and lower extremity to lower his or her body to the floor and sit on the strong buttock. The patient can adjust the body position as desired. To return to the wheelchair from the floor: • Instruct the patient to sit on the strong hip, facing the locked wheelchair with its caster wheels forward. The lower extremities should be flexed at the hips and knees. • Instruct the patient to reach to the back of the seat or the armrest and to pull himself or herself to a kneeling position. The patient moves to a half-kneeling position with the strong foot forward and flat on the floor and kneeling on the weak knee. • Instruct the patient to place the strong upper extremity on the near armrest or on the seat of the chair. The patient uses the strong extremities to push to a partial or full standing position facing the wheelchair. • Instruct the patient to reach for the far armrest with the strong upper extremity and to pivot on the strong lower extremity so that his or her back is toward the chair. • Then the patient lowers himself or herself into the chair using the strong extremities.51 Situation 2 • Instruct the patient to position the chair with the caster wheels Patient safety. forward, lock the chair, remove his or her feet from the footrests, and remove or swing away the front rigging. • Instruct the patient to move to the front of the chair. • Position the lower extremities to one side with the knees extended or flexed and positioned under the chair. • Instruct the patient to maintain one hand on the armrest or Patient safety. chair seat rail and to reach toward the floor with the other upper extremity while flexing his or her head and trunk. • After the hand has contacted the floor, the patient lowers himself or herself onto the floor and releases his or her grasp on the wheelchair. • The patient repositions himself or herself as desired.51 (continued) Copyright © 2002 F.A. Davis Company TRANSFER ABILITY, IMPAIRIED 353 (continued) ACTIONS/INTERVENTIONS RATIONALES To return to the wheelchair from the floor: • Instruct the patient to sit on one hip close to and facing the wheelchair with the hips and knees flexed. • The chair must be locked, the front rigging swung away, and Patient safety. the caster wheels positioned forward or turned to one side. • Instruct the patient to move to the front of the chair and to This method requires exceptional upper extremity strength and place one hand on the armrest or on the seat. trunk control, and the patient must have the ability to maintain • Have the patient grasp the armrest or the seat of the chair and his or her balance while in a high kneeling and push-up position. pull to a high kneeling position, maintaining his or her However, this is a safe and secure method, and many patients will balance. be able to perform it very efficiently.51 • Instruct the patient to grasp both armrests or to place one hand Caution: Many inactive or paralyzed patients may have osteoporosis on the seat of the chair and one hand on the armrest. in their lower extremities and vertebral bodies. Some of these • Have the patient perform a push-up to elevate the hips above transfer methods may be unsafe for these patients because of the the seat level. At the peak of the lift, the patient pivots so that floor reaction force that the patient may experience when he or she one hip is over the seat. drops onto the knees or hip. This force may be sufficient to cause a • Have the patient then release the innermost hand to lower one fracture in weakened bone. Therefore, the patient may need to be hip into the chair. assisted down to the floor to avoid injury.51 • The patient repositions the hands on the armrests and performs a push-up to position himself or herself in the chair.51 Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine all contributing factors, to include: All possible factors are considered in providing a holistic database � Neuromuscular for individualization. � Cardiovascular � Pulmonary � Cognitive � Developmental � Situational • Determine augmentive devices, personnel, or environmental Appropriate support ensures safety. needs. • Ascertain from the client all data to provide level of Prerequisite for each maneuver to increase likelihood of success. proprioception possible. • Determine strength and ability to coordinate body movements Pre-assessment helps ensure safety needs are met. well in advance of attempted maneuver. • Schedule transfer activities in a timely manner when possible. Time to adjust and slowly incorporate concept of transfer will be best afforded in a leisure vs. crisis time frame. • Determine readiness for taking on task of transfer. Validation of readiness offers empowerment and a sense of control in attempt. • Determine need for teaching the client, family, or other Teaching with focus on learner’s needs will most likely ease anxiety caregivers how to assist in transfer activities. and afford consistency in safe manner. • Determine a reward system to fit developmental status of the Provides reinforcement of desired behavior. client for appropriate attainment of goal. • Consider potential of group therapy in teaching transfer Group behavior offers peer support. activities. • Determine need for adaptation according to the patient’s status Principles of safety may be altered yet upheld for changes that and futuristic needs of change of environment. occur. • Allow sufficient time for teaching and mastery of transfer if Early teaching with plan for dismissal results in greater likelihood dismissal may occur within short period of time. of attainment and may be reason to keep patient until satisfied. Women’s Health The nursing actions for Women’s Health are the same as those for Adult Health. Psychiatric Health The nursing actions for the mental health client are the same as those for Adult Health. Gerontic Health The nursing actions for Gerontic Health are the same as those for Adult Health. Copyright © 2002 F.A. Davis Company 354 ACTIVITY-EXERCISE PATTERN Home Health ACTIONS/INTERVENTIONS RATIONALES • Educate the client, family, and potential caregivers about the Assists in avoiding injury. following: � Using proper body mechanics � Maintaining a clear wheelchair path • Assist the client in obtaining and proper use of a sliding board. Facilitates a safe transfer. • Assist the client in developing a schedule for range of motion To maintain and build muscle strength. exercises. • Refer clients for a home physical therapy consult to help them maximize their ability to safely use a wheelchair at home and to have assistive devices appropriate for the home environment. Copyright © 2002 F.A. Davis Company TRANSFER ABILITY, IMPAIRIED 355 Transfer Ability, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient independently transfer himself or herself? Yes No Record data, e.g., transfers with ease. Reassess using initial assessment factors. Requires no assistance. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can do limited transfer with assistance. Record CONTINUE Did evaluation show another and change target date. Modify nursing problem had arisen? Yes actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 356 ACTIVITY-EXERCISE PATTERN Walking, Impaired 4. Neuromuscular disorders 5. Amputation involving lower extremities DEFINITION Limitation of independent movement within the environment on foot.21 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; CLASS 2—ACTIVITY/EXERCISE Impaired Physical Mobility Impaired walking could be considered to be a subset of Impaired NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; Physical Mobility and is a more specific CLASS A—ACTIVITY AND EXERCISE MANAGEMENT diagnosis. If the patient is having difficulty only NOC: DOMAIN I—FUNCTIONAL HEALTH; with walking and not other aspects of mobility, CLASS C—MOBILITY such as moving in bed and getting up and down in sitting, then Impaired Walking is the most correct diagnosis. DEFINING CHARACTERISTICS21 Activity Intolerance This diagnosis relates 1. Impaired ability to climb stairs more to feeling fatigued or weakness while 2. Impaired

ability to walk required distances performing activities. Again, Activity 3. Impaired ability to walk on an incline or decline Intolerance is a broader diagnosis than 4. Impaired ability to walk on uneven surfaces Impaired Walking. 5. Impaired ability to navigate curbs RELATED FACTORS21 EXPECTED OUTCOME To be developed. Will independently walk by [date]. RELATED CLINICAL CONCERNS TARGET DATES 1. Arthritis Activities to facilitate walking with ease require weeks. An appro- 2. Chronic obstructive pulmonary disease priate evaluation target date would be 1 to 2 weeks from the day of 3. Cerebrovascular accident admission. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with Physical Therapy as needed. To assist in planning the ambulation activities. • Review the patient’s medical record for information. • Assess or evaluate the patient. To determine his or her limitations and capabilities to assist in planning the perambulation activities and gait pattern. • Determine the appropriate equipment and pattern based on the medical record, your assessment, and the goals of treatment. • Prepare the patient for ambulation (e.g., explain the gait pattern and improve physical abilities). • Remove items in the area that may interfere with ambulation. To maintain a safe environment. • Verify the initial measurement of the equipment. To ensure a proper fit and determine that the equipment is safe. • Always apply a gait belt to the patient in the early phases of Patient safety. treatment. • Be certain the patient is mentally and physically capable of performing the selected gait pattern. • Explain and demonstrate the gait pattern for the patient; ask To verify that he or she truly understands and comprehends your the patient to describe the pattern, how it is to be performed, instructions. and what he or she is expected to do. • Use the gait belt and the patient’s shoulder as points of control when guarding the patient. • Maintain proper body mechanics for yourself and the patient. (continued) Copyright © 2002 F.A. Davis Company WALKING, IMPAIRED 357 (continued) ACTIONS/INTERVENTIONS RATIONALES • Be sure the patient is wearing appropriate footwear; do not These conditions can lead to patient insecurity and injury as a result allow the patient to ambulate while wearing slippers or loosely of a fall. fitting shoes or while not wearing shoes. • Monitor the patient’s physiologic responses to ambulation frequently, and evaluate his or her vital signs, general appearance, and mental alertness during the activity. Compare your findings to normal values to determine the patient’s reaction to the activity. • Avoid guiding or controlling the patient by grasping his or her These items are insufficient to protect the patient. clothing on his or her upper extremity. • Expect the unexpected, and be alert for unusual patient actions or equipment problems; anticipate that the patient may slip or lose his or her stability or balance at any time. • Guard the patient by standing behind and slightly to one side of him or her, and maintain a grip on the gait belt until the patient is able to ambulate independently and safely. • Do not leave the patient unattended while he or she is standing. The patient may not be as stable as he or she appears or indicates to • Protect patient appliances (e.g., cast drainage tubes, intravenous you, and he or she could fall. lines, and dressings) during ambulation. • Be certain the area used for ambulation is free of hazards, such Safe conditions must be maintained to reduce the risk of injury to as equipment or furniture, and the floor or surface is dry.51 the patient. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all contributing factors including: A complete assessment provides primary database for � Orthopedic individualization. � Neurologic � Developmental � Situational • Monitor for clearance for weight-bearing or exact limit of Validation of status of limbs and their capacity for weight-bearing is activity with reliance on limbs, both lower and upper. critical for safety and non-injury before ambulation is considered. • Assess for need for assistive devices or personnel for walking Appropriate augmentive aids help ensure safe activity. activity. • Determine teaching needs for the client, family, or related Specific data for safety and likelihood of success is paramount for all assistants. involved to feel empowered. • Provide posture-appropriate alignment during walking Lessens likelihood of related injury to spine or limbs. activities. • Provide appropriate cautionary information when assistance is Ensures likelihood of safe walking with appropriate attention to required for the patient’s walking. State when, what must be limit setting to reinforce importance of plan. done, and with whom to meet prerequisite walking behaviors. • Coordinate health care team members and scheduling of The nurse is in the best position to provide safe and consistent care walking activities. with total patient needs in mind. • Provide safe environment, free of clutter or equipment, to Lessens the likelihood for barriers or obstacles to free path. degree possible. • Schedule medications to best enhance success in walking According to nature of medication, onset of action, half-life, side activities. effects, or untoward effects, the best likelihood for walking without undesired effects is upheld. • Seek assistance as required with Occupational and/or Physical Periodic regular assessment with appropriate health team members Therapy to maintain and progress in tolerance and appropriate provides appropriate validation for safe walking. reassessment for walking activities. • Determine an appropriate reward system according to the Reinforces desired behavior. patient’s developmental capacity. • Assess the patient’s potential for group teaching and walking Peer pressure and interaction offers diversionary stimulus to activity. perform desired activity. • If equipment is required, offer artistic opportunities for client to Self-expression provides a sense of identity for the client. decorate same per developmental interest. (continued) Copyright © 2002 F.A. Davis Company 358 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Determine need for dismissal planning well before actual event. Prior planning permits sufficient time to safely master walking protocol in a supportive environment. • Determine whether the client will later plan to attend school or Anticipation of usual events of daily living to be reincorporated in other regular activities with need for consideration of advance will lessen likelihood of potential unsafe potentials. modifications in current plan of ambulation. Women’s Health The nursing actions for Women’s Health are the same as those for Adult Health. Psychiatric Health The nursing actions for the mental health client are the same as those for Adult Health. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with physical therapist for assessment and treatment Physical therapists are health care professionals specializing in plan to improve walking ability. problems related to the lower extremities and ambulation skills. • Ensure that any adaptive or assistive equipment (such as braces, Reduces potential for injuries when the client is walking. footwear, or eyeglasses) fits correctly and is properly functioning. • Promote interdisciplinary team member communication to Ensures continuity of care across disciplines and care settings. ensure that plan of care is consistently applied. • Monitor and report symptoms as needed from medications Older adults may require medication adjustments to decrease side (e.g., antihypertensives, diuretics, or psychotropics) with side effects that have a deleterious effect on ambulation ability and effects such as lightheadedness or orthostatic blood pressure safety.91,92 changes that may affect the client’s ambulatory ability. • Encourage client participation in a walking program, if available Promotes the client’s physical and psychological well-being. in care setting. • Teach the client and/or caregivers to check for environmental Emphasizes safety focus prior to onset of activity. aids (e.g., handrails) or barriers (poorly fitting shoes, shiny floor surfaces, or cluttered pathways) to walking. • Promote use of activity programs, if available, that support the Provides increased opportunities for older adults to practice skills goal of increasing walking ability in clients (e.g., Senior Olympic to enhance walking ability. activities, exercises to promote lower extremity strengthening, or enhanced trunk control and balance abilities).92 Home Health ACTIONS/INTERVENTIONS RATIONALES • Educate the client, family, and potential caregivers about the following: � Using proper body mechanics to avoid injury. � Maintaining a clear walking path. � Installation of rails in the home to assist the client as he or she ambulates. � Eliminating throw rugs and cords that cross walking paths, because they increase the risk of falls. � The correct use of assistive devices. � Ensuring that all assistive devices are set to the correct height. • Assist the client in obtaining necessary durable medical equipment (e.g., crutches or walkers). • Refer the client for a home physical therapy consult to help maximize his or her ability to safely ambulate at home and to have assistive devices appropriate for the home environment. Copyright © 2002 F.A. Davis Company WALKING, IMPAIRED 359 Walking, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient walk independently? Yes No Record data, e.g., can walk unassisted, Reassess using initial assessment factors. as desired. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still requires assistance when walking. Record Did evaluation show another CONTINUE and change target date. problem had arisen? Yes Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 360 ACTIVITY-EXERCISE PATTERN Wandering 4. Separation from familiar people and places 5. Sedation DEFINITION 6. Emotional state, especially frustration, anxiety, boredom, or de- pression (agitated) Meandering, aimless, and/or repetitive locomotion, frequently in- 7. Physiologic state or need; for example, hunger, thirst, pain, uri- congruent with boundaries, limits or obstacles that expose the in- nation, or constipation dividual to harm.21 8. An over- or understimulating social or physical environment 9. Time of day NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; CLASS 2—ACTIVITY/EXERCISE RELATED CLINICAL CONCERNS NIC: DOMAIN 4—SAFETY; CLASS V—RISK 1. Dementia MANAGEMENT 2. Neurologic diseases impacting the brain NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 3. Head injuries CLASS J—NEUROCOGNITIVE 4. Medication side effects; for example, analgesics, sedatives, or hypnotics 5. Hyperthermia DEFINING CHARACTERISTICS21 1. Frequent or continuous movement from place to place, often revisiting the same destination(s) HAVE YOU SELECTED 2. Persistent locomotion in search of “missing” or unattainable THE CORRECT DIAGNOSIS? persons or places 3. Haphazard locomotion Disturbed Thought Process A disturbance in 4. Locomotion into unauthorized or private spaces thought processing could well lead to 5. Locomotion resulting in unintended leaving of the premise wandering; however, Wandering is a 6. Long periods of locomotion without an apparent destination specific physical behavior. Disturbed 7. Inability to locate significant landmarks in a familiar setting Thought Process is more specific to 8. Fretful locomotion or pacing cognition. 9. Locomotion that cannot easily be dissuaded or redirected Impaired Memory Impaired Memory could 10. Following behind or shadowing a caregiver’s locomotion also contribute to wandering, but again, 11. Trespassing Wandering is a specific physical behavior. 12. Hyperactivity Impaired Memory refers specifically to the 13. Scanning, seeking, or searching behaviors mental behavior of remembering. 14. Periods of locomotion interspersed with periods of nonloco- motion, for example, sitting, standing, or sleeping 15. Getting lost EXPECTED OUTCOME RELATED FACTORS21 Will have decrease in number of episodes of wandering by [date]. 1. Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, TARGET DATES language (primarily expressive) defects 2. Cortical atrophy Wandering needs to be monitored on a daily basis; however, a tar- 3. Premorbid behavior; for example, outgoing, sociable personal- get date of 5 days would be appropriate for initial evaluation of ity, premorbid dementia progress. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Review current medications, both prescription and May have adverse effects or interactions. over-the-counter. • Assess for depression. Psychiatric disorders may lead to wandering. • Assess for physical conditions such as infection, dehydration, Physical conditions may lead to wandering in the elderly. anemia, and respiratory, cardiovascular, or endocrine disorders. • Clear a safe area. Eliminate clutter or other hazards. Safety is the primary concern for patients who may wander. • Consider the use of weight alarm sensors or other types of alert Alarm will sound when the patient exceeds safety limits.93 sensors on the bed, chair, or wheelchair. (continued) Copyright © 2002 F.A. Davis Company WANDERING 361 (continued) ACTIONS/INTERVENTIONS RATIONALES • Check alarm systems on exit doors. Use a cloth panel to cover Alerts caregiver if the patient

opens the exit door. Cloth panel shiny push bar on an exit door. disguises push bar and does not draw the attention of the patient. • Have patient ID in clothes, on a bracelet or necklace, or wallet Assists in identifying the wandering patient. ID card. • Refer the family to the Alzheimer’s Association Safe Return Program: 1-800-272-3900. • Please refer to the Gerontic Health and Home Health Care plans for additional nursing actions. Child Health This diagnosis, according to its definition and defining characteristics, would not be appropriate for Child Health. Women’s Health Interventions for a Women’s Health client with this diagnosis would be the same as the interventions given in Adult Health and Gerontic Health. Psychiatric Health The mental health client with this diagnosis would require the same interventions as those given in Adult Health and Gerontic Health. Gerontic Health NOTE: Wandering, a behavior noted in clients with dementia, remains a perplexing activity for study and nursing interventions. Current research is attempting to describe and design assessments and nursing interventions for various types of wandering behavior.94 With this need for further investiga- tion in mind, the following actions are based on keeping clients safe, providing an outlet for stress and anxiety reduction, and providing environmental cues for clients. Nursing interventions should be adapted to meet the needs of the individual client who wanders. Some clients may favorably respond to interventions such as touch or music, whereas others may not. ACTIONS/INTERVENTIONS RATIONALES • Determine pattern of wandering and share observations with Knowledge of patterns can prompt caregivers to anticipate need for caregivers95 (e.g., the client wanders at certain times of day or activities or personal attention. evening or after visits from family or friends). • Ensure that the client has ID bracelet or necklace with his or Provides means of identification if the client becomes lost. her name and an emergency telephone number.96 • Monitor environment for possible safety hazards (e.g., toxic Decreases environmental injury risk. solutions or plants, electrical hazards, fire risks, or firearms).97 • Have poison control number available in the event of ingestion Decreased cognition may result in the client ingesting toxic of unsafe products. substances. • Encourage community-dwelling caregivers to enroll client in Provides organized response if the client becomes lost. Alzheimer’s Association Safe Return Program. • Ensure that there is an updated client photograph available. Assists in identification efforts. As dementia progresses, there may be marked changes in the client’s appearance. • Discourage access to exits by using electronic keypad alarm Provides audible alarm if door is opened without using the correct systems on doors. code. • Depending on care setting, promote group walking activity in Offers outlet for socializing and meeting the client’s activity and early afternoon or after evening meals.98 exercise needs. • Based on client preference, use music for 20–30 min before Music has been shown to reduce or eliminate agitation in some periods when the client is known to become increasingly clients affected with dementia.99 agitated. • Incorporate slow-stroke massage for brief periods (10–20 min) Slow-stroke massage has been helpful with some dementia clients to the client’s neck, shoulders, and back in early morning or in reducing the frequency and severity of agitation and the onset of late afternoon. aggressive behaviors.100 • Use familiar items, pictures, and furniture in the client’s Familiar objects may provide a sense of comfort for the client. surroundings. • Use distractions such as preferred activities, food, or fluids to Clients may not be able to recognize onset of fatigue when provide rest periods for the client. wandering. • Remove items from environment, such as coats, hats, or keys, Decreases stimulus for leaving the site. that may trigger wandering. (continued) Copyright © 2002 F.A. Davis Company 362 ACTIVITY-EXERCISE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Disguise doors by painting them the same color as the wall Difficult for the client to identify as an exit area. surface. • Place fabric strips attached to doorframes or stop signs on doors Signs or fabric strips often serve as deterrents to clients who wander. to prevent the client from entering areas that are “off limits.” • Use pictures and universal symbols for bathrooms, dining areas, Wanderers may no longer have ability to read and interpret signs or room identification. for these areas. • Arrange furniture areas where clients wander, to encourage Provides cues to clients for rest periods. resting spots. • Arrange repetitive activities for the client, such as linen folding, The client has opportunity for repetitive movement with less energy rocking, or paper work, if the client is engaged in “lapping type expended. wandering” and showing signs of fatigue.101 • Consider offering food, fluids, toileting, or pain medication Clients with decreased or absent verbal communication skills may when the client initiates wandering episodes, if this seems to be be unable to articulate these basic needs to caregivers. a need pattern for the client.101 Home Health ACTIONS/INTERVENTIONS RATIONALES • Consult with and/or refer the patient to assistive resources such Utilization of existing services is an efficient use of resources. as caregiver support groups, as needed. • When wandering is related to inappropriate responses to cues, May help prevent episodes of wandering and subsequent injury. adapt the environment to change the cues: � Cover doorknobs � Remove keys that are in a visible location � Remove knobs from oven and stove • Ensure that the environment is as safe as possible when To prevent injury in the event of wandering by the client. wandering occurs: � Remove knobs from oven and stove. � Alert neighbors that the client may wander, and inform them about actions to take when the client is found wandering. • Provide the client with an ID bracelet indicating numbers where To minimize the time the client is away from caregivers in the caregivers can be reached. event of wandering. • Assist the client and caregiver in obtaining alarm systems to To alert the caregiver if the client begins to wander. indicate when doors have been opened. Copyright © 2002 F.A. Davis Company WANDERING 363 Wandering FLOWCHART EVALUATION: EXPECTED OUTCOME Audit chart. Has the patient had a decrease in episodes of wandering over past 5 days? Yes No Record data, e.g., has had no episodes Reassess using initial assessment factors. of wandering for past 5 days. Consistent orientation  3 for past 4 days. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., had 5 episodes of wandering on day of admission; has Did evaluation show another averaged 5 episodes per day for past problem had arisen? Yes 5 days. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 364 ACTIVITY-EXERCISE PATTERN Wheelchair Mobility, Impaired HAVE YOU SELECTED DEFINITION THE CORRECT DIAGNOSIS? Limitation of independent operation of wheelchair within environ- ment.21 Impaired Physical Mobility Impaired Wheelchair Mobility could be considered as a subset of Impaired Physical Mobility. NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; Certainly a patient who had Impaired CLASS 2—ACTIVITY/EXERCISE Wheelchair Mobility would also have NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; Impaired Physical Mobility. Impaired CLASS C—IMMOBILITY MANAGEMENT Wheelchair Mobility would need to be resolved before Impaired Physical Mobility. NOC: DOMAIN II—FUNCTIONAL HEALTH; Activity Intolerance If the patient could CLASS C—MOBILITY tolerate only minimal activities before having problems, then Activity Intolerance DEFINING CHARACTERISTICS21 would be the priority diagnosis. Only after Activity Intolerance has been resolved would 1. Impaired ability to operate manual or power wheelchair on even the nurse be able to effectively intervene for or uneven surface Impaired Wheelchair Mobility. 2. Impaired ability to operate manual or power wheelchair on an incline or decline 3. Impaired ability to operate wheelchair on curbs EXPECTED OUTCOME RELATED FACTORS21 Will complete wheelchair mobility training program by [date]. To be developed. TARGET DATES RELATED CLINICAL CONCERNS Resolution of this diagnosis may vary from weeks to months. An 1. Fracture appropriate initial evaluation target date would be 1 to 2 weeks af- 2. Paralysis ter the date the diagnosis was established. 3. Neuromuscular disorders 4. Nutritional deficiencies NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with Physical Therapy as needed. To assist in planning activities to improve the patient’s ability to independently operate a wheelchair within the environment. • Reinforce instructions from Physical Therapy. • Assist the patient with strengthening exercises as appropriate. • Assist the patient with functional wheelchair activities as needed. • Encourage the patient to participate as much in care as possible. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine contributing factors to best consider highest potential A full assessment of contributing factors offers the most holistic for self vs. assistive needs. approach to determine degree of assistance needed. • Identify priorities of basic functions as breathing, airway Basic physiologic functioning must be provided for if the movement maintenance, cardiovascular endurance, tolerance of positioning, is to be successful and not bring about alterations to basic proprioception and neuromuscular coordination. functions. • Define limitations of tolerance for positioning, movement, and Critical thresholds will assist in defining reasonable likelihood for ideal plan for mobility. success. (continued) Copyright © 2002 F.A. Davis Company WHEELCHAIR MOBILITY, IMPAIRED 365 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assess for equipment or assistive equipment needed. Stabilization and use of appropriate assistive devices offer likelihood of success without injury. • Anticipate safety needs and environmental considerations Anticipatory safety is inherent in all mobility endeavors and serves related to safety needs. to prevent injury. • According to maternal and infant or maternal and child dyad or Caregiver input serves to put the infant or child at ease with caregiver status, decide who will assist in mobility activities. likelihood of success, plus provides an important opportunity for sense of input by the patient. • Assess for medication implications for movement timing and The best likelihood for desired effects will be related to appropriate best potential for desired effects in relation to mobility, freedom medication correlation with related mobility or position. of undesired effects, or contraindication of related treatments. • Establish a plan for each 8-h period to include the maneuvers to Regular scheduled movement with attention to prescribed be carried out, equipment or personnel needed, and critical assessments, documentation, and awareness of thresholds assists in thresholds to be attended to as dictated per patient’s status; i.e., maintaining the client’s stable status. pulse oximeter level above [specify], pulse range [specify], etc. • Note critical thresholds and report as appropriate to physician as Ongoing assessment and appropriate reporting of critical thresholds may be ordered or expected depending on the patient’s status. will maintain desired stability of the client and provide basis for setting limits or increasing limits. • Determine outcomes according to previous baseline or desired If it takes a period of time more than 3 to 4 days, subgoals will level of activity. (May require subgoals over a longer period of better reflect the incremental change or gradual attainment of a time.) greater goal. • Coordinate mobility activities as necessary with appropriate Each person’s input is best utilized in a manner of patient-centered health team members to include physical therapy, occupational planning to afford optimum likelihood of success and not tire the therapy, child life specialist, etc. patient, vs. fragmented, duplicated or less than individualized efforts for mobility. Women’s Health The nursing actions for Women’s Health are the same as those for Adult Health. Psychiatric Health The nursing actions for the mental health client are the same as those for Adult Health. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Obtain consultation with occupational and physical therapists Occupational and physical therapists are health care professionals to determine treatment plan for the client. best suited to evaluate the client and design treatment regimen. • Check wheelchair for proper fit for the client (adequate seat Proper fit enhances the client’s ability to control wheelchair. width, appropriate armrest height, and level of footrests). • Provide positive feedback when the client correctly manipulates Positive feedback encourages the desired behavior. wheelchair. • Ensure environment where the client is active is accessible by Adapted environment supports wheelchair use. wheelchair (e.g., width of doorframes, table height, ramps, and curb cuts present in walkways). • Promote interdisciplinary communication to ensure that Clearly

described and communicated treatment goals assist treatment plan is followed. caregivers in providing care and feedback. • Review with the client and/or caregiver teaching plan for Provides opportunities to evaluate learning and address any wheelchair use. questions related to wheelchair use. Home Health ACTIONS/INTERVENTIONS RATIONALES • Educate the client, family, and potential caregivers about the following: � Using proper body mechanics to avoid injury � Maintaining a clear wheelchair path • Assist the client in developing a schedule for range of motion To maintain and build muscle strength. exercises. • Refer the client for a home physical therapy consult. To help maximize his or her ability to safely use a wheelchair at home and to have assistive devices appropriate for the home environment. Copyright © 2002 F.A. Davis Company 366 ACTIVITY-EXERCISE PATTERN Wheelchair Mobility, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient completed the wheelchair mobility training program? Yes No Record data, e.g., completed wheelchair Reassess using initial assessment factors. program 2 days ago. Having no problems with wheelchair mobility. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., dropped out of program after 3 days. States “don’t Did evaluation show another need to do this. My wife will wheel problem had arisen? Yes me around.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 6 Sleep-Rest Pattern 1. SLEEP DEPRIVATION 369 2. SLEEP PATTERN, DISTURBED 375 Pattern Description spinal cord, and cerebral cortex and the bulbar synchronizing portion in the medulla. These two systems function intermittently by acti- The sleep-rest pattern includes relaxation in addition to sleep and vating and suppressing the higher centers of the brain. rest. The pattern is based on a 24-hour day and looks specifically After falling asleep, a person passes through a series of stages that at how an individual rates or judges the adequacy of his or her afford rest and recuperation physically, mentally, and emotionally. sleep, rest, and relaxation in terms of both quantity and quality. The In stage 1, the individual is in a relaxed, dreamy state, aware of his pattern also looks at the patient’s energy level in relation to the or her surroundings. In stages 2 and 3, there is progression to deeper amount of sleep, rest, and relaxation described by the patient as levels of sleep in which the individual becomes unaware of his or her well as any aids to sleep the patient uses. surroundings but wakens easily. In stage 4, there is profound sleep characterized by little body movement and difficult arousal. Stage 4 restores and allows the body to rest. These stages are known as Pattern Assessment non–rapid eye movement (NREM) sleep. Stage 5 is called rapid eye movement (REM) sleep. It is in this stage that the individual dreams. 1. Does the patient report a problem falling asleep? Other characteristics of this stage of sleep are irregular pulse, vari- a. Yes (Disturbed Sleep Pattern) able blood pressure, muscular twitching, profound muscular relax- b. No ation, and an increase in gastric secretions.1 After REM sleep, the in- 2. Does the patient report interrupted sleep? dividual progresses back through stages, 1, 2, and 3 again. a. Yes (Sleep Deprivation) A person’s age, general health status, culture, and emotional b. No well-being dictate the amount of sleep he or she requires. On the whole, older persons require less sleep, whereas young infants re- Conceptual Information quire the most sleep. As the nurse assesses the patient’s needs for sleep and rest, he or she makes every effort to individualize the care A person at rest feels mentally relaxed, free from anxiety, and phys- according to this sleep-rest cycle. A major emphasis is to provide ically calm. Rest need not imply inactivity, and inactivity does not patient education regarding the influence of disease process on necessarily afford rest. Rest is a reduction in bodily work that re- sleep-rest patterns. sults in the person’s feeling refreshed and with a sense of readiness Reports of the occurrence of excessive and pathologic sleep most to perform activities of daily living. commonly relate to narcolepsy and hypersomnia. Narcolepsy is Sleep is a state of rest that occurs for sustained periods. The re- characterized by an attack of irresistible sleep of brief duration with duced consciousness during sleep provides time for essential repair “auxiliary” symptoms. In sleep paralysis, the narcoleptic patient is and recovery of body systems. A person who sleeps has temporar- unable to speak or move and breathes in a shallow manner. Audi- ily reduced interaction with the environment. Sleep restores a per- tory or visual hypnagogic hallucinations may occur. Cataplexy, a son’s energy and sense of well-being. brief form of narcolepsy, is an abrupt and reversible decrease or loss Studies have confirmed that sleep is a cyclical phenomenon. The of muscle tone and is most often elicited by emotion. The attacks most common sleep cycle is the 24-hour, diurnal day-night cycle. may last several seconds and almost go undetected, or they may last This 24-hour cycle is also referred to as the circadian rhythm. In gen- as long as 30 minutes with muscular weakness being evident. In the eral, light and darkness govern the 24-hour circadian rhythm. Addi- initial stage of the attack, consciousness remains intact.2 tional factors that influence the sleep-wake cycle of the individual are Hypersomnia, in contrast, is characterized by daytime sleepiness biologic, such as hormonal and thermoregulation cycles. Most indi- and sleep states that are less imperative and of longer duration than viduals attempt to synchronize activity with the demands of modern those in narcolepsy. Often a deepening and lengthening of night society. The two specialized areas of the brain that control the cycli- sleep is also noted. Sleep apnea and the Kleine-Levin syndrome are cal nature of sleep are the reticular activating system in the brain stem, two examples of the hypersomnia disorders.2 367 Copyright © 2002 F.A. Davis Company 368 SLEEP-REST PATTERN Sleep apnea may occur in patients with a damaged respiratory as do a large number of physiologic variables. This period of cen- center in the brain, brain stem infarction, drug intoxication (bar- tral nervous system (CNS) reorganization (with a likely increased biturates, tranquilizers, etc.), bilateral cordotomy, and Ondine’s vulnerability) is immediately followed by a short transient interval curse syndrome. Patients with the typical pickwickian syndrome at 3 months of age in which play and wakefulness—and, within it, show marked obesity and associated alveolar hypoventilation, sleep the basic rest-activity cycle—show excessive regularity. This regu- apnea, and hypersomnia. There are several forms of this condition larity may carry its own risk. that may exist without obesity. One such syndrome is Ondine’s The study of mobility has proved worthwhile in detecting the ori- curse syndrome, which involves the loss of the automaticity of gin of the basic rest-activity cycle in the fetus. Neonatologists, who breathing and manifests during sleep as a recurrent apnea. Another deal with the immature infant, often use mobility in prognosis. is the Kleine-Levin syndrome, which is associated with periods of Apneas during sleep are common in normal infants and occur hypersomnia accompanied by bulimia or polyphagia and mental most often during the newborn period, with a marked decrease in the disturbances. There is also a cyclic hypersomnia reported that is re- first 6 months of life. Long apneas, longer than 15 seconds, are not lated to the premenstrual periods. The typical syndrome, pick- usually observed during sleep in laboratory conditions. Obstructive wickian, is rare, whereas the atypical variants seem more common.2 apneas of 6 to 10 seconds are also rarely observed. However, in lab- Various factors influence a person’s capability to gain adequate oratory studies, paradoxical breathing is observed in neonates, and rest and sleep. For the home setting, it is appropriate for the nurse periodic breathing is associated with REM sleep in normal infants.4 to assist the patient in developing behavior conducive to rest and Infants found not breathing by parents are usually rushed to the relaxation. In a health care setting, the nurse must be able to pro- hospital. Causes for life-threatening apnea to be investigated in- vide ways of promoting rest and relaxation in a stressful environ- clude congenital conditions, especially cardiac disease or arrhyth- ment. Loss of privacy, unfamiliar noises, frequent examinations, tir- mias; cranial, facial, or other conditions affecting the anatomy of the ing procedures, and a general upset in daily routines culminate in airway; infections such as sepsis, meningitis, pneumonia, botulism, a threat to the client’s achievement of essential rest and sleep. and pertussis; viral infections such as respiratory syncytial virus; metabolic abnormalities; administration of sedatives; seizures; and Developmental Considerations chronic hypoxia. If these causes are ruled out, the infant is diag- nosed as having “apnea of infancy.” Sleep studies, with polygraph In general, as age increases, the amount of sleep per night decreases. recordings, are required. The term near miss sudden infant death syn- The length of each sleep cycle—active (REM) and quiet (NREM)— drome (near miss SIDS) implies the child is found limp, cyanotic, changes with age. For adults, there is no particular change in the and not breathing and would have died had caretakers not inter- actual number of hours slept, but there is a change in the amount vened. Because the relation of the near miss SIDS event to SIDS is of deep sleep and light sleep. As a person ages, the amount of deep speculative, apnea of infancy is the preferred term.4 sleep decreases and the amount of light sleep increases. This helps Obstructive and central apnea identification, hypopnea, pro- explain why the older patient wakens more easily and spends time longed expiration, apnea and reflux, and apnea and cardiac arrhyth- in sleep throughout the day and night. REM sleep decreases in mia are the current issues being studied in trying to solve this prob- amount from the time of infancy (50 percent) to late adulthood (15 lem. For any infant-related apnea, hospitalization, with special percent). The changes in sleep pattern with age development are3: observation for all possible contributing factors and close monitoring of cardiac and respiratory function, is recommended. Attention must Infant: Awake 7 hours; NREM sleep 8.5 hours; REM sleep, 8.5 be given to parents for the extreme anxiety this problem creates. hours The newborn and young infant spends more time in REM sleep Age 1: Awake 13 hours; NREM sleep, 7 hours; REM sleep, than adults do. As the infant’s nervous system develops, the infant 4 hours will have longer periods of sleep and wakefulness that become more Age 10: Awake 15 hours; NREM sleep, 6 hours; REM sleep, regular. At approximately 8 months of age, the infant goes through 3 hours the stage of separation anxiety with potentially altered sleep pat- Age 20: Awake 17 hours; NREM sleep, 5 hours; REM sleep, terns. Teething, ear infections, or other disorders affect sleeps pat- 2 hours terns. Respirations are quiet, with minimal activity noted during Age 75: Awake 17 hours; NREM sleep, 6 hours; REM sleep, deep sleep. The infant sleeps an average of 12 to 16 hours per day. 1 hour TODDLER AND PRESCHOOLER INFANT The toddler needs approximately 10 to 12 hours of sleep at night, The development of sleep and wakefulness can be traced to in- with an approximate 2-hour nap in the afternoon. The percentage trauterine life. A gestational age of 36 weeks seems to be a land- of REM sleep is 25 percent. Rituals for preparation for sleep are im- mark, for it is at this time that the behavioral states in the fetus and portant, with bedtime associated as separation from family and fun. preterm infant begin to take on a more mature character. The join- Quiet time to gradually unwind, a favorite object for security, and ing of physiologic variables results in identification of recurrent be- a relatively consistent bedtime are suggested. Nightmares may be- havioral states with various parameters. Term birth leads to a num- gin to occur because of magical thinking. ber of profound changes, especially in respiratory regulation, but The preschooler sleeps approximately 10 to 12 hours per day. more evidence

suggests that continuity of development, rather than Dreams and nightmares may occur at this time, and resistance to bed- discontinuity, prevails.4 time rituals is also common. Unwinding or slowing down from the The newborn begins life with a regular schedule of sleep and ac- many activities of the day is recommended to lessen sleep disturbances. tivity that is evident during periods of reactivity. For the first hour, Actual attempts to foster relaxation by mental imaging at this age have infants born of unmedicated mothers spend 60 percent of the time proved successful. The percentage of REM sleep is 20 percent. in the quiet, alert state and only 10 percent of the time in the irri- Special needs may be prompted for the toddler during hospital- table, crying state. Five distinct sleep-activity states for the infant ization. When at all possible, a parent’s presence should be en- have been noted5: (1) regular sleep, (2) irregular sleep, (3) drowsi- couraged throughout nighttime to lessen fears. Limit setting ness, (4) alert inactivity, and (5) waking and crying. with safety in mind is also necessary for the toddler because of his After 1 month of age, sleep and wakefulness change dramatically or her surplus of energy and the desire for constant activity. The Copyright © 2002 F.A. Davis Company SLEEP DEPRIVATION 369 preschooler may be at risk for fatigue. Sleep may not be necessary and napping in the daytime.9 The proportion of REM sleep may at naptime, but rest without disturbance is recommended to sup- vary from 20 to 25 percent; however, deep sleep (stage 4 NREM plement night sleep and to prevent fatigue. sleep) is decreased. There is no clinical evidence showing that older adults require less sleep, but evidence exists showing that older SCHOOL-AGE CHILD adults sleep less and sleep less well.10 Obstructive sleep apnea, pe- riodic limb movement disorder, and restless leg syndrome are The school-age child seems to do well without a nap and requires ap- common sleep disorders found in the older population.11 Circadian proximately 10 hours of sleep per day, with REM sleep being ap- rhythm changes with aging can cause changes in the older adult’s proximately 18.5 percent. Individualized rest needs are developed by sleep-wake cycle that result in poor nighttime sleep and increased this age, with a reliable source being the child who can express his or daytime napping. her feelings about rest or sleep. Health status would also determine Sleep pattern disturbances in the elderly may occur as a result of to a great extent how much sleep the child at this age requires. Per- undiagnosed depression or medication-induced sleep problems. mission to stay up late must be weighed against the potential upset Other risk factors interfering with sleep may include unrelieved to routine and demands of the next day. When bedtime is assigned pain, alcohol use, lack of daytime activity, nocturia, or medical con- a status, peer pressure and power issues may ensue. ditions such as dementia.12 Older adults involved in caregiving for When the school-ager alters the usual routines of sleep and rest, people with dementia are at risk for developing sleep deprivation fatigue may be a result. Attempts should be made to maintain usual as the dementia progresses.13 Institutionalized older adults may re- routines even when school is not in session to best maintain the port problems with sleeping if their usual sleep pattern does not co- usual sleep-rest pattern. incide with the facility schedule. Individualized attention to sleep and potential fatigue is critical ADOLESCENT to prevent further decreases in activity and changes in self-worth for older adults. Fatigue plays a major role in determining the qual- Irregular sleep patterns seem to be the norm for the adolescent as a ity and amount of musculoskeletal activity engaged in by the el- result of high activity levels and usual peer-related activities. There derly. Poor sleep may affect rehabilitation potential, alertness, may be a tendency to overexertion, which is made more pro- safety, and psychological comfort. Examining factors that may in- nounced by the numerous physiologic changes that create in- fluence fatigue is an essential part of the assessment for sleep-rest creased demands on the body. Fatigue may occur during this time. pattern. On the average, the adolescent sleeps approximately 8 to 10 hours per day, with REM sleep being 20 percent. Rest may be necessary to supplement sleep. Supplementing sleep with rest serves to assist in preventing illness or the risk of illness. APPLICABLE NURSING DIAGNOSES Extracurricular activities may also need to be prioritized. Sleep Deprivation ADULT DEFINITION The adult sleeps approximately 8 hours per day, with REM sleep Prolonged periods of time without sleep (sustained, natural, peri- being 22 percent. Sleep patterns may be subject to demands of odic suspension of relative consciousness).14 young infants or children in the household or after-hours profes- sional and social activities. The adult may be at high risk for fatigue because of increasing NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; role expectations, especially in the instance of a new baby being CLASS 1—SLEEP/REST cared for. Sleep deprivation is not a positive means of coping with NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; the many expectations the adult may feel. CLASS F—SELF-CARE FACILITATION Research has shown that women of all ages have higher rates of sleep disturbance than men. Some speculation has occurred that re- NOC: DOMAIN I—FUNCTIONAL HEALTH; lates this to the reproductive lives of women and hormonal CLASS A—ENERGY MAINTENANCE changes. It is well documented that the psychosocial and hormonal changes that accompany pregnancy lead to sleep disturbances.6 DEFINING CHARACTERISTICS14 That sleep deprivation occurs during the postpartum period is a well-known fact. A new baby does not allow for a mother’s unin- 1. Daytime drowsiness terrupted sleep for approximately 4 to 6 weeks after birth.7,8 2. Decreased ability to function Sleep disturbance seen in women who are experiencing peri- 3. Malaise menopausal and menopausal symptoms is often related to declin- 4. Tiredness ing estrogen levels. “Disrupted sleep is one of the earliest effects on 5. Lethargy the brain of decreasing levels of estrogen.”6 Sometimes these sleep 6. Restlessness changes begin as much as 8 to 10 years before menses cease, and 7. Irritability research has proved that sleep deprivation not only causes sup- 8. Heightened sensitivity to pain pression of the immune system but is a major factor in causing per- 9. Listlessness sistent fatigue. 10. Apathy 11. Slowed reaction OLDER ADULT 12. Inability to concentrate 13. Perceptual disorders (e.g., disturbed body sensation, delu- As adults age, they are more likely to report sleeping difficulties. As sions, and feeling afloat) many as 50 percent of people age 65 and older complain of sleep 14. Hallucinations problems on a regular basis. Complaints often include sleeping less, 15. Acute confusion frequent nighttime awakening, waking too early in the morning, 16. Transient paranoia Copyright © 2002 F.A. Davis Company 370 SLEEP-REST PATTERN 17. Agitated or combative 13. Sundowner’s syndrome 18. Anxious 14. Narcolepsy 19. Mild, fleeting nystagmus 15. Idiopathic central nervous system hypersomnolence 20. Hand tremors 16. Sleepwalking 17. Sleep terror RELATED FACTORS14 18. Sleep-related enuresis 19. Nightmares 1. Prolonged physical discomfort 20. Familial sleep paralysis 2. Prolonged psychological distress 21. Sleep-related painful erections 3. Sustained inadequate sleep hygiene 22. Dementia 4. Prolonged use of pharmacologic or dietary antisoporifics 5. Aging-related sleep stage shifts RELATED CLINICAL CONCERNS 6. Sustained circadian asynchrony 7. Inadequate daytime activity 1. Colic 8. Sustained environmental stimulation 2. Hyperthyroidism 9. Sustained unfamiliar or uncomfortable sleep environment 3. Anxiety 10. Non–sleep-inducing parenting practices 4. Chronic obstructive pulmonary disease 11. Sleep apnea 5. Pregnancy; postpartum period 12. Periodic limb movement (e.g., restless leg syndrome and noc- 6. Pain turnal myoclonus) 7. Alzheimer’s disease HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping Patients sometimes activities. However, assessment documents that use sleep as an avoidance mechanism and will this fatigue exists regardless of the amount of sleep. report “not getting enough sleep” when in fact Disturbed Sleep Pattern Sleep Deprivation refers there is no sleep deprivation. A review of the specifically to a decreased amount of sleep; number of hours of sleep would indicate the Disturbed Sleep Pattern refers to multiple problems patient is getting a sufficient amount of sleep. with sleeping. Disturbed Sleep Pattern would likely Fatigue The patient will talk about lack of energy result in Sleep Deprivation. and difficulty in maintaining his or her usual EXPECTED OUTCOME TARGET DATES Will sleep, uninterrupted, for at least 6 to 8 hours per night by The suggested target date is no less than 2 days after the date of the [date]. (Note: The actual hours of uninterrupted sleep will depend diagnosis and no more than 5 days. This length of time will allow on the patient’s age and developmental level.) for initial modification of the sleep pattern. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Avoid coffee or cola, which contain caffeine, from late Caffeine is a stimulant that interferes with sleep. afternoon on. • Avoid over-the-counter pain relievers that contain caffeine from late afternoon on. • Avoid cold medicines that contain pseudoephedrine and Pseudoephedrine and phenylpropanolamine as well as other phenylpropanolamine from late afternoon on. adrenergics act as stimulants.15 • Avoid alcohol at night. Alcohol interferes with substances in the brain that allow for continuous sleep. • Adjust the timing of diuretics to avoid nighttime trips to the Waking to go to the bathroom will interfere with sleep. bathroom. • Check for other prescription drugs taken to determine Side effects of some prescriptions include sleep pattern disturbances. whether they may interfere with sleep patterns, e.g., antidepressants, thyroid medication, etc. (continued) Copyright © 2002 F.A. Davis Company SLEEP DEPRIVATION 371 (continued) ACTIONS/INTERVENTIONS RATIONALES • Avoid eating a heavy meal late at night. However, a small snack Heavy meals increase stomach acid and intestinal stimulation. A such as warm milk or chamomile tea may be relaxing. light snack may allay hunger pains.16 • Consider herbal solutions such as valerian. However, watch for Reduces the time it takes to get to sleep but does not seem to reduce side effects such as headaches, nausea, blurred vision, heart the number of times people wake in the night. palpitations, and paradoxically, excitability and restlessness. Do not take concurrently with other sleep aids or alcohol. • Assess the patient’s mattress and pillow. Is it too hard or soft? The mattress is an important component of restful sleep. Is it offering enough support? • Check for mild iron deficiency. Vitamin E may also help with Even a low-normal iron level may cause restless leg syndrome. restless leg syndrome. • Teach the patient to try relaxation techniques such as meditation, counting your breaths, slowly tensing and relaxing muscles, guided imagery, etc. just before bedtime. • Encourage the patient to exercise early in the day rather than at Exercise stimulates the body. night. • Counsel the patient to not “take problems to bed.” He or she Helps clear the patient’s mind, order his or her problems, and set should sit quietly in a chair for a few minutes before going to his or her plans for the next day.15 bed and think about all those things that have worried him or her during the day. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine all possible contributing factors that may impact Provides a database for individualization of care. sleep deprivation (including situational, environmental, or those related to another medical condition). • Stabilize those factors that can be stabilized to minimize Affords a better picture of actual causative factors for sleep contributing factors: deprivation. � Clustering activities to not disturb unnecessarily. � Providing as near to normal routine for sleep for the client, with attention to developmental needs (as noted in under Conceptual Information). • Consider reassessment on an ongoing basis for disruptive In a short period of time there may be significant changes to contributing factors. consider for accurate sleep assessment. • Based on assessments, develop a restructured plan for sleep Restructuring may afford sleep and awake cycles to recur. allowance by eliminating, to degree possible, all factors identified to be barriers to sleep. • Determine teaching needs of the client, parents, or caregivers. Specific knowledge regarding sleeping and waking cycles facilitates individualized match of needs for clients and caregivers. • Reevaluate measures to define the optimum likelihood for sleep Possible growth and developmental phases may be required for to occur

as desired. appropriate reestablishment of cycles. • Implement appropriate nursing measures as noted for sleep Once major factors are stabilized, basic maneuvers to encourage disturbance as applicable. sleep may be afforded per prior successful plan with allowance for updated developmental needs. • Monitor for caregiver frustration in attempts to deal with sleep Parents will often be subject to sleep deprivation of the infant or deprivation secondary to caregiver role strain. child. • Assist the parents in identification of ways to deal with sleep Empowerment for possible solutions offers growth potential as deprivation of the infant or child. parents. • Reassure the parents or, if applicable, the child of likelihood for Ability to cope with problem is increased when individuals believe regular sleep pattern to be reestablished with sufficient time and problem is manageable. allowance for recycling. • Determine effect sleep deprivation may have over time, Related physiologic alterations often ensue related to sleep monitoring every 8 h to note related alterations, with attention deprivation. to basic physiologic parameters as indicated per the client’s condition and needs. • Monitor for mental and cognitive capacity, with attention to Identification of related onset of interference in usual mental or subjective or behavioral changes. behavioral domain will help minimize greater disturbance of the client’s status. • Ensure safety needs are met at all times. Altered sleep and wake cycles may alter usual proprioception or cognitive ability. Copyright © 2002 F.A. Davis Company 372 SLEEP-REST PATTERN Women’s Health Nursing actions for the Women’s Health client with this diagnosis are the same as those actions for Adult Health with the following exceptions: ACTIONS/INTERVENTIONS RATIONALES • Assess the client for feelings of sleepiness or drowsiness during Disruptive sleep patterns can lead to problems with memory and the day. are associated with daytime drowsiness, fatigue, feeling “foggy” mentally along with disturbances in memory, concentration, and libido. • If the client is reporting perimenopausal symptoms and As estrogen levels drop, the brain responds with bursts of disturbances in memory at any age, but particularly in the adrenalin-type chemicals that arouse one from sleep. Prolonged 30s, 40s, and 50s, refer to physician for hormonal evaluation. periods of sleep disruption can be a cause of biochemical changes, which can lead to chronic fatigue and depression.6 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with physician and pharmacist to assess for Sleep disorders such as sleep apnea and certain medical conditions physiologic and pharmacologic factors that contribute to can contribute to sleep deprivation by disruption of normal sleep wakefulness. patterns.17–19 • Assess the client’s use of caffeine, alcohol, tobacco, and other Use of certain chemicals can contribute to sleep disturbance by substances. (This can be accomplished with a sleep journal.) increasing central nervous system stimulation.19 • Assess the client for changes in normal activity patterns. (This Changes in environmental conditions can contribute to sleep can be accomplished with a sleep journal.) disturbance. Exercise near bedtime can cause stimulation and make it difficult to begin sleep. Irregular daily cycles can interfere with sleep patterns. Also the client’s perceived sleep time may differ from actual time.19 • Sit with the client for [number] minutes each shift to discuss Emotional stressors can increase anxiety and decrease the client’s current stressors. ability to relax sufficiently to sleep normally.18 • Spend 30 min each shift in the first 24 h to review with the client Understanding the client’s perception of the situation of past the strategies he or she has used to improve sleep. Validate and solutions facilitates change. Decreases feelings of isolation, and normalize the client’s responses. Note persons responsible for creates perception of a manageable problem.20,21 this here. • Develop with the client a plan to limit caffeine-containing Caffeine and nicotine stimulate the central nervous system.19 beverages and nicotine 4 h before bedtime. Note that plan here. • Develop with the client a plan for positive reinforcement for Positive reinforcement strengthens desired behaviors.19 accomplishing the goals established. Note the behaviors to reward and the rewards here. • Develop an exercise schedule, and note schedule and type of Exercise promotes normal daytime fatigue and facilitates normal exercise here. Arrange schedule so the client is not exercising sleep patterns. just before bedtime. • Spend [number] minutes [times a day] assisting the client with Concerns not addressed in a constructive manner can contribute to problem solving at least 2 hours before bedtime. nighttime wakefulness. Stress before bedtime can inhibit normal sleep.22 • Establish bedtime routine with the client. Note the client’s Routine promotes relaxation.19 routine here. • Provide a light, high-carbohydrate snack before bedtime. Note Hunger can interfere with normal sleep patterns. Carbohydrates the client’s preference here. increase tryptophan, which facilitates the development of serotonin. Serotonin promotes sleep.19 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Teach the older adult or caregiver to maintain his or her daily Avoid further changes in circadian rhythm. schedule of rising, resting, and sleeping. • Encourage the older adult to use progressive muscle relaxation Progressive muscle relaxation has been found to be an effective as a strategy to promote sleep. nonpharmacologic intervention to improve sleep onset and quality in older adults.23 (continued) Copyright © 2002 F.A. Davis Company SLEEP DEPRIVATION 373 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide caregivers with information on community resources, Assists caregivers in reducing sense of isolation and stress.13 stress management, and ways to reduce disruptive behaviors when caring for people with dementia. • Consult with physician for possible evaluation of sleep disorder. Because sleep problems are assumed to be normal aging by elderly and health care professionals, sleep disorders are often not evaluated or treated.9 Home Health ACTIONS/INTERVENTIONS RATIONALES • Maintain client safety: Basic safety measures. � Ensure that the client does not attempt to drive while sleep deprived. � Ensure that the client does not try to cook while sleep deprived. • Reinforce in writing any client education that occurs while the Ensures that the content is available for review as needed. client is sleep deprived. • Manage pain quickly and effectively. Pain can contribute to further sleep deprivation, and the client experiences heightened sensation of pain when sleep deprived. • Identify predisposing factors, and eliminate those factors that contribute to the present sleep deprivation and that place the client at risk for exacerbation of existing problems: � Pain or other symptoms that are not properly managed � Environmental disturbances, such as outside lights or noises � Frequent interruptions during normal sleep times � The use of prescription or over-the-counter medications that disrupt REM sleep • Encourage self-care, exercise, and activity as appropriate and Sleep and rest patterns are stabilized by a balance of activity and based on medical diagnosis and client condition. exercise. Copyright © 2002 F.A. Davis Company 374 SLEEP-REST PATTERN Sleep Deprivation FLOWCHART EVALUATION: EXPECTED OUTCOME Review chart for past 48 hours. Audit hours of sleep. Is the patient sleeping uninterrupted for at least 6–8 h per night? Yes No Record data, e.g., chart documents Reassess using initial assessment factors. patient has slept uninterrupted for at least 6 h per night for the past 48 h. Patient’s comments validate amount of uninterrupted sleep. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., chart documents sleeping uninterrupted for only 4 h Did evaluation show another per night. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SLEEP PATTERN, DISTURBED 375 Sleep Pattern, Disturbed o. Daylight or darkness exposure p. Grief DEFINITION q. Anticipation r. Shift work Time-limited disruption of sleep (natural, periodic suspension of s. Delayed or advanced sleep phase syndrome consciousness) amount and quality.14 t. Loss of sleep partner, life change u. Preoccupation with trying to sleep NANDA TAXONOMY: DOMAIN 4—ACTIVITY/REST; v. Periodic gender-related hormonal shifts CLASS 1—SLEEP/REST w. Biochemical agents x. Fear NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; y. Separation from significant others CLASS F—SELF-CARE FACILITATION z. Social schedule inconsistent with chronotype aa. Aging-related sleep shifts NOC: DOMAIN I—FUNCTIONAL HEALTH; bb. Anxiety CLASS A—ENERGY MAINTENANCE cc. Medications dd. Fear of insomnia DEFINING CHARACTERISTICS14 ee. Maladaptive conditioned wakefulness ff. Fatigue 1. Prolonged awakenings gg. Boredom 2. Sleep maintenance insomnia 2. Environmental 3. Self-induced impairment of normal pattern a. Noise 4. Sleep onset longer than 30 minutes b. Unfamiliar sleep furnishings 5. Early morning insomnia c. Ambient temperature, humidity 6. Awakening earlier or later than desired d. Lighting 7. Verbal complaints of difficulty falling asleep e. Other-generated awakening 8. Verbal complaints of not feeling well rested f. Excessive stimulation 9. Increased proportion of stage 1 sleep g. Physical restraint 10. Dissatisfaction with sleep h. Lack of sleep privacy or control 11. Less than age-normal total sleep time i. Nurse for therapeutics, monitoring, or laboratory tests 12. Three or more nighttime awakenings j. Sleep partner 13. Decreased proportion of stages 3 and 4 sleep (e.g., hypore- k. Noxious odors sponsiveness, excess sleepiness, and decreased motivation) 3. Parental 14. Decreased proportion of REM sleep (e.g., REM rebound, hy- a. Mother’s sleep-wake pattern peractivity, emotional lability, agitation and impulsivity, and b. Parent-infant interaction atypical polysomnographic features) c. Mother’s emotional support 15. Decreased ability to function 4. Physiologic a. Urinary urgency RELATED FACTORS14 b. Wet c. Fever 1. Psychological d. Nausea a. Ruminative presleep thoughts e. Stasis of secretions b. Daytime activity pattern f. Shortness of breath c. Thinking about home g. Position d. Body temperature h. Gastroesophageal reflux e. Temperament f. Dietary RELATED CLINICAL CONCERNS g. Childhood onset h. Inadequate sleep hygiene 1. Colic i. Sustained use of antisleep agents 2. Hyperthyroidism j. Circadian asynchrony 3. Anxiety k. Frequent changing sleep-wake schedule 4. Depression l. Depression 5. Chronic obstructive pulmonary disease m. Loneliness 6. Any postoperative state n. Frequent travel across time zones 7. Pregnancy; postpartum period Copyright © 2002 F.A. Davis Company 376 SLEEP-REST PATTERN HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Sleep Pattern rarely requires stress, anxiety, fear, and so on. These patients will differentiation from any other diagnoses and is invariably be requesting “a sleeping pill.” quite often a companion diagnosis for any Fatigue With this diagnosis, the patient will talk hospitalization. about lack of energy and difficulty in maintaining Ineffective Individual Coping In some instances, his or her usual activities of daily living. However, patients will use sleep as an avoidance mechanism when questioned, it will be revealed that this and might report a sleep pattern disturbance when fatigue exists in spite of the amount of sleep. in reality there is no disturbance. Review of the Activity Intolerance Again, a lack of energy will number of hours of sleep would indicate the patient be reported, but there will be no report of has a normal sleep pattern but desires to increase inadequate sleep. Indeed, the hours of sleep may the amount of sleep to avoid having to deal with have increased. EXPECTED OUTCOME TARGET DATES Will verbalize decreased number of complaints regarding loss of The suggested target date is no less than 2 days after the date of di- sleep by [date]. agnosis and no more than 5 days. This length of time will allow for initial modification of the sleep pattern. NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Teach relaxation exercises as needed. Decreases sympathetic response and decreases stress. • Suggest sleep-preparatory activities such as quiet music, warm These winding-down activities promote sleep. Carbohydrates fluids, and decreased active exercise at least 1 h prior to stimulate secretion of insulin. Insulin decreases all amino acids but scheduled sleep time. Provide a high-carbohydrate snack. tryptophan. Tryptophan in larger quantities in the brain increases production of serotonin, a neurotransmitter that induces sleep.24 • Provide warm, noncaffeinated fluids after 6 p.m.; limit fluids Warm drinks are relaxing. Limiting fluid reduces the chance of after 8 p.m. midsleep interruption to go to the bathroom. • Assist to bathroom or bedside commode, or offer bedpan at The urge to void may interrupt the sleep cycle during the night. 9 p.m. Voiding immediately before going to bed lessens the probability of this occurring. • Schedule all patient therapeutics before 9 p.m. Promotes uninterrupted sleep. • Maintain room temperature at 68–72F. Environment temperature that is the most conducive to sleep. • Notify operator to hold telephone calls

starting at 9 p.m. Promotes uninterrupted sleep. • Ensure adherence, as closely as possible, to the patient’s usual Follows the patient’s established pattern; promotes comfort; and bedtime routine. allows the patient to wind down. • Close door to room; limit traffic into room beginning at least Reduces environmental stimuli. 1 h before scheduled sleep time. • Administer required medication, e.g., analgesics, sedative, after Promotes action and effect of medication; allows evaluation of all daily activities and therapeutics are completed. Monitor medication effectiveness; and provides data for suggesting changes effectiveness of medication 30 min after time of administration. in medication if needed. • Give back massage immediately after administering medication. Relaxes muscles and promotes sleep. If no medications are needed, give back massage after toileting. • Place the patient in preferred sleeping position; support position Promotes the patient’s comfort, and follows the patient’s usual with pillows. routine. • Ascertain whether the patient would like a night light. Promotes sense of orientation in an unfamiliar environment. • Once the patient is sleeping, place “do not disturb” sign on door. Promotes uninterrupted sleep. • Increase exercise and activity during day as appropriate for the Promotes regular diurnal rhythm. patient’s condition. • When appropriate, discuss reasons for sleep pattern disturbance; Promotes adaptation that can increase sleep. teach appropriate coping mechanisms. Copyright © 2002 F.A. Davis Company SLEEP PATTERN, DISTURBED 377 Child Health ACTIONS/INTERVENTIONS RATIONALES • Give warm bath 30 min to 1 h before scheduled sleep time. Promotes relaxation, and provides quiet time as a part of the sleep routine. • Feed 15–30 min before scheduled sleep time—formula, snack In young infants and small children, a sense of fullness and satiety, of protein and simple carbohydrate, no fats. without difficulty in digestion, promotes sleep without the likelihood of upset or disturbances. • Implement usual bedtime routine: rocking, patting, child A structured approach to setting limits while honoring individual cuddling of favorite stuffed animal, or using special blanket. preference. Provides security and promotes sleep. • Read a calm, quiet story to the child immediately after putting Reading allows a passive, meaningful enjoyment that occupies the to bed. attention of the young child while creating a bond between the caretaker and child. Serendipitous relaxation often follows. • Provide environment conducive to sleep—room temperature of Lack of unpleasant stimuli will provide sensory rest, as well as a 74–78F, soft, relaxing music, or night light. chance to tune out need for cognitive-perceptual activity. • Restrict loud physical activity at least 2–3 h before scheduled Overstimulating physical activity may signal the central nervous sleep time. system to activate bodily functions. • Schedule therapeutics around sleep needs. Complete all The nurse’s valuing of the sleep schedule will convey respect for therapeutics at least 1 h before scheduled sleep time. the importance of sleep to the patient and family. • Assist the parents with defining and standardizing general Parents will be able to cope better with developmental issues given waking and sleeping schedule. the knowledge and opportunity to inquire about sleep-related issues. It is reported that limit setting with confidence by parents is the most effective way to develop healthy patterns of sleep when no related health problems exist. • Teach the parents and child appropriate age-related relaxation Improves parents’ coping skills in dealing with common techniques, e.g., imagination of the “most quiet-place game,” developmental issues that affect sleep. and other imaging techniques. • Discuss with the parents difference between inability to sleep and fears related to developmental crises: � Infant and toddler: Separation anxiety � Preschooler: Fantasy versus reality � School-age: Ability to perform at expected levels � Adolescent: Role identity versus role diffusion • Ensure the child’s safety according to developmental and Basic safety standards for infants and children. psychomotor abilities, e.g., infant placed on side or back; no plastic, loose-fitting sheets; and bedrails to prevent falling out of bed. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to schedule rest breaks throughout day. Knowledge and proper planning can help the patient reduce fatigue during pregnancy and the immediate postpartum period. • Review daily schedule with the patient, and assist the patient to Knowledge of life changes can help in planning and implementing adjust sleep schedule to coincide with the infant’s sleep pattern. mechanisms to reduce fatigue and sleep disturbance. • Identify a support system that can assist the patient in alleviating fatigue. • Assist the patient in identifying lifestyle adjustments that may be needed because of changes in physiologic function or needs during experiential phases of life, e.g., pregnancy, post partum, or menopause: � Possible lowering of room temperature � Layering of blankets or covers that can be discarded or added as necessary � Practicing relaxation immediately before scheduled sleep time � Establishing a bedtime routine, e.g., bath, food, fluids, or activity (continued) Copyright © 2002 F.A. Davis Company 378 SLEEP-REST PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Involve significant others in discussion and problem-solving activities regarding life-cycle changes that are affecting work habits and interpersonal relationships, e.g., hot flashes, pregnancy, or postpartum fatigue. • Teach the patient to experiment with restful activities when she cannot sleep at night rather than lying in bed and thinking about not sleeping. • Discuss with women the following to assess sleep pattern disturbance: � Do they have an irregular sleep-wake pattern? � Do they have problems falling asleep at night? � Do they regularly wake up several times at night and have difficulty falling back asleep? � Do they feel sleepy or drowsy during the day? � Assess for snoring, jerky movements during sleep, or stoppage of breathing during sleep. (Can assess in sleep lab or question the client’s sleeping partner.) • Collaborate with the woman’s physician, and recommend an For women in midlife, restless sleep with several awakenings may evaluation of hormone levels and/or further evaluation of sleep be one of the earliest indicators of declining estrogen. Sleep apnea disorders. can lead to sexual dysfunction, major depression, high blood pressure, chronic fatigue, problems with memory and concentration during the day, and potentially a heart attack.6 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Provide only decaffeinated drinks during all 24 h. Caffeine stimulates the central nervous system. • Spend [amount] minutes with the client in activity of the client’s Increases mental alertness and activity during daytime hours. choice at least twice a day. • Provide appropriate positive reinforcement for achievement of Positive reinforcement encourages behavior. steps toward reaching a normal sleep pattern. • Talk the client through deep muscle relaxation exercise for Facilitates relaxation and disengagement from the activities and 30 min at 9 p.m. thoughts of the day to prepare the client both physically and mentally for sleep. • Sit with the client for [amount] minutes 3 times a day in a quiet Positive reinforcement encourages calm behavior and enhances environment, and provide positive reinforcement for the client’s self-esteem. accomplishments. (Note: This is for clients with increased activity.) • Go to the client’s room and walk with him or her to the group Stimulates wakefulness during daytime hours, and facilitates the area 3 times a day. development of a trusting relationship. • Spend time out of the room with the client until he or she Stimulates wakefulness during daytime hours. demonstrates ability to tolerate 30 min of interaction with others.25 (Note: This is for clients with depressed mood.) • Spend 30 min with the client discussing concerns 2 h prior to Facilitates problem solving during daytime hours at a time when bedtime. normal sleep patterns will not be disturbed. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with the physician and the pharmacist, if a sleeping This ensures that the older adult has as natural a sleep pattern as medication is prescribed, to ensure that the drug is one that possible. minimally interferes with the normal sleep cycle. • Monitor for the presence of pain prior to bedtime and if the Untreated pain may prevent the onset of sleep and interrupt the patient is found awake frequently during the night. individual’s usual sleep pattern. • Monitor for symptoms of depression,26 especially if the older Depression is frequently underreported and undertreated in older adult reports waking very early in the morning with an inability adults. to fall back to sleep and experiencing feelings of anxiety upon awakening. Copyright © 2002 F.A. Davis Company SLEEP PATTERN, DISTURBED 379 Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning, implementing, and Household involvement is important to ensure the environment is promoting restful environment and sleep routine: conducive for sleep and rest. � Close door to room. � Turn room lights off, and provide small night light. � Pull blinds to shield from street lights (at night) or sunlight (daytime). � Limit activity in room beginning at least 30 min before scheduled sleep time. � Unplug telephone in room, or adjust volume control on bell. � Coordinate family activities and the client’s sleep needs to maximize both schedules. � Request that visits and calls be at specified times so that sleep time is not interrupted. � Provide favorite music, pillows, bedclothes, teddy bears, etc. � Provide optimal room temperature and ventilation. � Support usual bedtime routine as much as possible in relation to medical diagnosis and the client’s condition. � Assist the client with bedtime routine as necessary. • Maintain pain control via appropriate medications, body Pain disturbs or prevents sleep and rest. positioning, and relaxation. • Encourage self-care, exercise, and activity as appropriate and Sleep-rest patterns are stabilized by a balance of activity and based on medical diagnosis and client condition. exercise. Copyright © 2002 F.A. Davis Company 380 SLEEP-REST PATTERN Sleep Pattern, Disturbed FLOWCHART EVALUATION: EXPECTED OUTCOME Review chart. How many statements regarding loss of sleep or inadequate rest did the patient make on admission day? Interview the patient. How many statements today? Have complaints decreased? Yes No Record data, e.g., made six comments in Reassess using initial assessment factors. first 24 h of admission re: inadequate sleep; no comments in past 48 h. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., made 10 comments in last 24 h regarding inadequate rest. Did evaluation show another Record CONTINUE and change target problem had arisen? Yes date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 7 Cognitive-Perceptual Pattern 1. ADAPTIVE CAPACITY, INTRACRANIAL, 6. MEMORY, IMPAIRED 416 DECREASED 385 7. PAIN, ACUTE AND CHRONIC 421 2. CONFUSION, ACUTE AND 8. SENSORY PERCEPTION, DISTURBED CHRONIC 391 (SPECIFY: VISUAL, AUDITORY, 3. DECISIONAL CONFLICT KINESTHETIC, GUSTATORY, (SPECIFY) 400 TACTILE, OLFACTORY) 431 4. ENVIRONMENTAL INTERPRETATION 9. THOUGHT PROCESS, SYNDROME, IMPAIRED 406 DISTURBED 440 5. KNOWLEDGE, DEFICIENT 10. UNILATERAL NEGLECT 447 (SPECIFY) 410 Pattern Description 2. Does the patient have a problem with appropriate response to stimuli? Rationality, the ability to think, has often been described as the defin- a. Yes (Confusion) ing attribute of human beings. Thus, the cognitive-perceptual pattern b. No becomes the essential premise for all other patterns used in the prac- 3. Does the patient have a problem with fluctuating levels of con- tice of nursing. Because this pattern deals with the adequacy of the sciousness (in presence of inappropriate response to stimuli)? sensory modes and adaptations necessary to negate inadequacies in a. Yes (Acute Confusion) the cognitive functional abilities, any failure in recognizing alterations b. No (Chronic Confusion) in this pattern will hamper assessment and intervention in all the 4. Does the patient indicate difficulty in making choices between other patterns. The nurse must be aware of the cognitive-perceptual options for care? pattern as an integral and important part of holistic nursing. a. Yes (Decisional Conflict [Specify]) The cognitive-perceptual pattern deals with thought, thought b. No processes, and knowledge as well as the way the patient acquires 5. Is the patient delaying decision making regarding care options? and applies knowledge. A major component of the process is per- a. Yes (Decisional Conflict [Specify]) ceiving. Perceiving incorporates the interpretation of sensory stim- b. No uli. Understanding how a patient thinks, perceives, and incorpo- 6. Has the patient been disoriented to person, place, and time for rates these processes to best adapt and function is paramount in

more than 3 months? assisting the patient to return to or maintain the best health state a. Yes (Impaired Environmental Interpretation Syndrome) possible. Alterations in the process of cognition and perception are b. No an initial step in any assessment. 7. Can the patient respond to simple directions or instructions? Additionally, the nurse-patient relationship identifies human re- a. Yes sponse as a major premise for the nursing process. Ultimately, then, b. No (Impaired Environmental Interpretation Syndrome) it is this very notion of thought and learning potential that facili- 8. Does the patient indicate lack of information regarding his or her tates the self-actualization of human beings. problem? a. Yes (Deficient Knowledge [Specify]) Pattern Assessment b. No 9. Can the patient restate the regimen he or she needs to follow for 1. Does intracranial pressure fluctuate following a single activity? improved health? a. Yes (Decreased Intracranial Adaptive Capacity) a. Yes b. No b. No (Deficient Knowledge [Specify]) 381 Copyright © 2002 F.A. Davis Company 382 COGNITIVE-PERCEPTUAL PATTERN 10. Can the patient remember events occurring within the past 4 The second approach is based on the work of the Swiss psychol- hours? ogist Jean Piaget, who considered cognitive adaptation in terms of a. Yes two basic processes: assimilation and accommodation. Assimilation b. No (Impaired Memory) is the process by which the person integrates new perceptual data 11. Review the mental status examination. Is the patient fully alert? or stimulus events into existing schemata or existing patterns of be- a. Yes havior. In other words, in assimilation, a person interprets reality b. No (Disturbed Thought Process or Disturbed Sensory in terms of his or her own model of the world based on previous Perception) experience. Accommodation is the process of changing that model 12. Does the patient or his or her family indicate that the patient the individual has of the world by developing the mechanisms to has any memory problems? adjust to reality. Piaget believed that representational thought does a. Yes (Disturbed Thought Process) not originate in a social language but in unique symbols that pro- b. No vide a foundation later for language acquisition.1 13. Review sensory examination. Does the patient display any The American psychologist Jerome Bruner broadened Piaget’s sensory problems? concept by suggesting that the cognitive process is affected by three a. Yes (Disturbed Sensory Perception [Specify]) modes: the enactive mode involves representation through action, b. No the iconic mode uses visual and mental images, and the symbolic 14. Does the patient use both sides of body? mode uses language.1 a. Yes Cognitive dissonance is the mental conflict that takes place when b. No (Unilateral Neglect) beliefs or assumptions are challenged or contradicted by new in- 15. Does the patient look at and seem aware of the affected body formation. The unease or tension the individual may experience as side? a result of cognitive dissonance usually results in the person’s re- a. Yes sorting to defense mechanisms in an attempt to maintain stability b. No (Unilateral Neglect) in his or her conception of the world and self. 16. Does the patient verbalize that he or she is experiencing pain? In a broad sense, thinking activities may be considered internally a. Yes (Acute Pain; Chronic Pain) adaptive responses to intrinsic and extrinsic stimuli. The thought b. No processes serve to express inner impulses, but they also serve to 17. Has the pain been experienced for more than 6 months? generate appropriate goal-seeking behavior by the individual. Per- a. Yes (Chronic Pain) ceptual processes enhance this behavior as well. b. No (Acute Pain) Perception is the process of extracting information in such a way 18. Does patient display any distraction behavior (moaning, cry- that the individual transforms sensory input into meaning. The ing, pacing, or restlessness)? senses, which serve as the origin of perceptual stimuli, are as follows: a. Yes (Pain) b. No 1. Exteroceptors (distance sensors) a. Visual b. Auditory Conceptual Information 2. Proprioceptors (near sensors) a. Cutaneous (skin senses that detect and communicate or A person who is able to carry out the activities of a normal cognitive- transduce changes in touch, e.g., pressure, temperature, and perceptual pattern experiences conscious thought, is oriented to pain) reality, solves problems, is able to perceive via sensory input, and b. Chemical sense of taste responds appropriately in carrying out the usual activities of daily c. Chemical sense of smell living in the fullest level of functioning. All these functions rely on 3. Interoceptors (deep sensors) a healthy nervous system containing receptors to detect input ac- a. Kinesthetic sense that senses changes in position of the body curately, a brain that can interpret the information correctly, and and motions of the muscles, tendons, and joints transmitters, which can transport decoded information. Bodily re- b. Static or vestibular sense that senses changes related to main- sponse is also a basic requisite to respond to the sensory and per- taining position in space and the regulation of organic functions ceptual demands of the individual. such as metabolism, fluid balance, and sensual stimulation Cognition is the process of obtaining and using knowledge about one’s world through the use of perceptual abilities, symbols, and It is important to note that because perceptual skill processing is reasoning. For this reason, it includes the use of human sensory ca- an internal event, its presence and development are inferred by pabilities to receive input about the environment. This process usu- changes in overt behavior. For full appreciation of the cognitive- ally leads to perception, which is the process of extracting informa- perceptual pattern, it is also necessary to understand the normal tion in such a way that the individual transforms sensory input into physiology of the nervous system. meaning. Cognition incorporates knowledge and the process used in its acquisition; therefore, ideas (concepts of mind symbols) and language (verbal symbols) are two tools of cognition. Learning may Developmental Considerations be considered the dynamic process in which perceptual processing of sensory input leads to concept formation and change in behav- INFANT ior. Cognitive development is highly dependent on adequate, pre- dictable sensory input. The full-term newborn has several sensory capacities. The neonate There are two general approaches to contemporary cognitive the- should have a pupillary reflex in response to light and a corneal re- ory. The information-processing approach attempts to understand flex in response to touch. The sensory myelination is best devel- human thought and reasoning processes by comparing the mind oped at birth for hearing, taste, and smell. with a sophisticated computer system that is designed to acquire, Vision The eye is not structurally completely differentiated from the process, store, and use information according to various programs macula. The newborn has the capacity to momentarily fixate on a or designs. bright or moving object held within 8 inches and in the midline of the Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 383 visual field. By approximately 4 months of age, the infant is capable startle, response to sudden loss of support or loud noises. The of 20/200 visual acuity. Binocular fixation and convergence to near neonate is dependent on others for protection from pain. The objects is possible by approximately 4 months of age. In a supine po- mother of a newborn is most often the person who assumes this task, sition, the infant follows a dangling toy from the side to past midline. along with the father and other primary caregivers. For this reason, management of pain must also include the parents. Distraction, for Hearing The neonate is capable of detecting a loud sound of ap- example, a pacifier, is useful in dealing with painful stimuli. proximately 90 decibels and reacts with a startle. At birth, all the The infant gradually offers localized reaction in response to pain structural components of the ear are fully developed. However, the at approximately 6 to 9 months of age. Still, the cognitive abilities lack of cortical integration and full myelination of the neural path- of the infant remain limited with respect to pain. Often a physical ways prevents specific response to sound. The infant will usually tugging of the painful body part proves to be the clue of pain for search to locate sounds. By approximately 15 months of age, the in- the infant, as with an earache. The infant is incapable of offering co- fant is beginning to acquire eye-hand coordination and is capable operation in procedures and must be physically restrained, because of accommodation to near objects. Of concern at this age would be he or she is largely incapable of resisting painful stimuli. Crying and any abnormalities noted in any of these tasks plus rubbing of eyes, irritability may also be manifestations of pain, particularly when the self-rocking, or other self-stimulating behavior. By approximately 2 nurse is sure other basic needs have been attended to. months, the infant will turn to the appropriate side when a sound If chronic pain comes to be a way of life for the infant soon after is made at ear level. By approximately 20 months, the infant will lo- birth or before much development has occurred, there may be al- calize sounds made below the ear. A cause for concern might be terations in any of the subsequent development. In some instances, failure to be awakened by loud noises or abnormal findings in any infants adapt and develop high tolerances for pain. of the previously mentioned responses. Speech or the uttering of The neonate is dependent on others for appropriate care and sounds by age 6 to 8 months would also be a component. health maintenance. Values for health care are being formed Smell Smell seems to be a factor in breastfed infants’ response to through this provision of care by others. The infant will gradually the mother’s engorgement and leaking. Newborns will turn away continue to learn values of health care. Safety becomes an ongo- from strong odors such as vinegar and alcohol. By approximately 6 ing concern as has been previously acknowledged. Parents or pri- to 9 months, the infant associates smell with different foods and fa- mary caregivers assume this responsibility. The infant is capable miliar people of his or her circle of activity. Avoidance of strong, of object permanence but cannot be expected to remember ab- unpleasant odors occurs also. stract notions. The neonate subjected to hypoxia in the perinatal period is at risk Taste The newborn responds to various solutions with the follow- for possible future developmental delays. Apgar scores are typically ing facial reflexes: used as criteria, in addition to neurologic reflexes. Seizures during 1. A tasteless solution elicits no facial expression. the neonatal period must also be followed up. In a general sense, 2. A sweet solution elicits an eager suck and look of satisfaction. the premature infant of less than 38 weeks’ gestation should also be 3. A bitter liquid produces an angry, upset expression. considered at risk for developmental delays. It is paramount that close examination be performed for basic primitive reflexes and By 1 year of age, the infant shows marked preferences, with sim- general neonatal status as well as identification of any genetic syn- ilar responses to different flavors as did the young neonate. dromes or congenital anomalies. The infant gradually incorporates symbols and interacts with the Touch At birth, the neonate is capable of perception of touch, and world through primary caregivers. Any major delays in development the mouth, hands, and soles of the feet are the most sensitive. There should be cause for further close follow-up. Sensory-perceptual de- is increasing support for the notions that touch and motion are es- ficiencies may indeed bring about impaired thought processes. sential to normal growth and development. By 1 year of age, the infant has a preference for soft textures over rough, grainy textures. The infant relies on the sense of touch for TODDLER AND PRESCHOOLER comforting. Overresponse or underresponse to stimuli, for exam- Binocular vision is well established by now. The toddler can dis- ple, pain, is a cause for concern. tinguish geometric shapes and can demonstrate beginning depth perception. Marked strabismus should be treated at this time to Proprioception The infant, at birth, is limited in perceiving itself in prevent amblyopia. The toddler can begin to name colors. space, because this requires deep myelination and total integration of Smell,

taste, and touch all become more related as the toddler ini- cortical activity. There is momentary head control. In general, refer- tially sees an object and handles it while enjoying, via all the senses, ral to more exacting neurologic reflexes of the neonate will provide what it is to “know.” Regression to previous tactile behavior for in-depth supplementary data. In essence, primitive reflexes, which comfort is common in this group, as exemplified by a preference are protective in nature, serve to assist the neonate in adjustment to for being patted and rocked to sleep during times of stress, such as extrauterine life and identification of congenital anomalies. A critical illness. Concerns by this time would be for secondary deficits in de- appreciation of organic and operational synergy for the central ner- velopment that may arise. There is also a great concern for the tod- vous system is necessary as sensory deficits are considered. dler who shows greater response to movement than to sound or By approximately 3 months of age, the infant will, when sus- who avoids social interaction with other children. By this time, pended in a horizontal prone position with the head flexed against speech should be sufficiently developed to validate a basic sense of the trunk, reflexively draw up the legs—this is known as the Lan- the toddler’s ability to use symbols. Proprioception is not perfected, dau reflex. It remains present until approximately 12 to 24 months but “toddling” represents a major milestone. Falls at this age are of age. Another related reflex is the parachute reflex, in which the common. infant, on being suspended in a horizontal prone position and sud- There is an even greater incorporation of sensory activity in se- denly thrust downward, will place hands and fingers forward as an quencing for the preschooler, in whom major myelination for the attempt to protect himself or herself from falling. This reflex ap- most part is fully developed. There is refinement of eye-hand coor- pears at approximately 7 months and persists indefinitely. dination, and reading readiness is apparent. Visual acuity begins to The neonate responds with total body reaction to a painful stim- approach 20/20, and the preschooler will know colors. Before the ulus. The primitive reflexes demonstrate this, especially the Moro, or age of 5, the child should be screened for amblyopia; after age 5, Copyright © 2002 F.A. Davis Company 384 COGNITIVE-PERCEPTUAL PATTERN there is minimal potential for development of amblyopia. Language as implications for possible recurrence. The child of this develop- becomes more sophisticated and serves to provide social interac- mental category will attempt to hold still as needed, with an ap- tion. By this age, the child will remember and exercise caution re- pearance of bravery. Expression of the experience of pain is to be garding potential dangers, such as hot objects. expected by a school-ager. If the school-ager is particularly shy, The toddler may regress to previous behavior levels with physical special attempts should be made to establish a trusting relationship resistance in response to painful stimuli. This will be especially true to best manage pain. A major fear is loss of control. The nurse must with invasive procedures. On occasion, a toddler may demonstrate consider the need to completely evaluate chronic pain. In some in- tolerance for painful procedures on the basis of understanding ben- stances, it may signal other altered patterns, especially a distressed efits offered, for example, young children with a medical diagnosis of family or inability to cope. Lower performance in school can be an leukemia. This is not the usual case, however. Temper tantrums, out- indicator of chronic pain. Also, the nurse should be aware of the in- bursts, and avoidance of painful stimuli describe the usual behavior creased complexity required for daily activities of living. The child of the toddler. When the toddler must deal with chronic pain, he or of this age may feel negative about himself or herself if he or she is she may regress to previous behavior as a means of coping. unable to perform as peers do. The importance of group activities The preschooler views any invasive procedure as mutilation and cannot be overstressed. attempts to withdraw in response to pain. The preschooler cries out The school-age child will blossom with a sense of accomplish- in pain and will express feelings in his or her own terms as de- ment. When school does not bring success, frustration follows. It is scriptors of pain. The interpretation of pain is influenced greatly by mandatory that caution be exercised in assessing for deficits versus the parental and familial value systems. In severe pain, the poten- behavioral manifestations of not liking school. tial for regression to previous behavior is high. The nurse should be aware that fears of abandonment, death, or the unknown would be ADOLESCENT brought out by pain for this age group. Also, the effect the pain has on others may serve to further frighten the child. Vision Acuity of 20/20 is reached by now. Squinting should be in- Play is an ideal noninvasive means of assessment. Difficulties in vestigated, as should any symptoms of prolonged eyestrain. gait, balance, or the use of upper limbs in symmetry with lower Hearing Further investigation should be done on any adolescent limbs should be noted, as well as related holistic developmental who speaks loudly or who fails to respond to loud noises. components including speech, motor, cognitive, perceptual, and social components. Allowance should be made for regression to Touch Overreaction or underreaction to painful stimuli is cause prior patterns as needed in times of stress, such as illness and hos- for further investigation. pitalization. If a deficit exists, parents should be encouraged to con- Taste The adolescent may prefer food fads for a length of time, but tinue appropriate follow-up and intervention. concern would be appropriate if the adolescent overuses spices, The preschooler may be aware of how he or she is different from especially salt or sugar, or complains of foods not “tasting as they peers, although egocentrism continues. Of importance is the mas- used to.” tery of separation from parents for increasing periods of time. The likelihood of sibling integration should be considered also. At this Smell The adolescent should distinguish a full range of odors. The time, a known neglect of one side of the body may be problematic, nurse should be concerned if the adolescent is unresponsive to nox- as the child may rebel and fail to comply with desired therapy. ious stimuli. The toddler gradually learns to care for himself or herself and is Proprioception There may be temporary clumsiness associated strongly influenced by the family’s value system. There is capacity with growth spurts. The nurse should be concerned if he or she ob- for expression of beginning thoughts. serves patterns of deteriorating gross and fine motor coordination The preschooler has capacity for magical thinking and enjoys and ataxia. role-play of the parent of the same sex. At this age, beginning re- sistance to parental authority is common, and the child is still ego- By now the adolescent is capable of formal operational thought centric in thought. This makes it difficult to apply universal under- and is able to move beyond the world of concrete reality to abstract standing of use of language and symbols for children of this age, for possibilities and ideas. Problem solving is evident with inductive example, death may be perceived as “sleep.” and deductive capacity. There is an interest in values, with a ten- By this age, there should be a general notion of the cognitive ca- dency toward idealism. Attention must be given to the adolescent’s pacity for the child. The child explores the world in a meaningful sensitivity to others and potential for rejection if body image is al- fashion and still relies closely on primary caregivers. If there are tered. Of particular importance at this time are sports and peer- marked delays, they should be monitored with a focus on main- related activities. As feelings are explored more cautiously, there is taining optimum functioning with developmental sequencing. a tendency to draw into oneself at this stage. There may be major The preschooler will enjoy activity and is beginning to enjoy conflicts over independence when self-care is not possible. learning colors, using words in sentences, and gradually forming The adolescent fears mutilation and attempts to deal with pain as relationships with persons outside the immediate family. If there an adult might. Self-control is strived for, with allowance for capi- are delays, they should continue to be monitored. By now, major talization on gains from pain. Sexuality factors of role performance deficits in cognition become more obvious. enter into this group as pain occurs. As with the adult, an attempt to discover the cause and implication of the pain is made. The ado- lescent experiencing chronic pain will be at risk for abnormal peer SCHOOL-AGE CHILD interaction and may potentially endure altered self-perception. The adolescent will most often remain steady in cognitive func- The school-ager has a significant ability to perform logical opera- tioning if there are no major emotional or sensory problems. Of tions. More complete myelination and maturation enhance the ba- concern at this age would be substance abuse that could impair sic physiologic functioning of the central nervous system. Gener- thought processes. ally, the school-age child can establish and follow simple rules. There is self-motivation with a gradual grasp of time in a more ab- ADULT AND OLDER ADULT stract nature. The concept of death is recognized as permanent. The school-age child begins to interpret the experience of pain Vision The adult is capable of 20/20 vision with a gradual decline with a cognitive component—the cause or source of pain, as well in acuity and accommodation after approximately 40 years of age. Copyright © 2002 F.A. Davis Company ADAPTIVE CAPACITY, INTRACRANIAL, DECREASED 385 There is a tendency toward farsightedness. Color discrimination With aging, there is a gradual loss of balance, perhaps most re- decreases in later ages, with green and blue being the major hues lated to the concurrent vascular changes. For this reason proprio- affected. Depending on the cause, there is a great potential for the ceptive data may provide an immediate basis for safety needs of the use of corrective aids. In examples of degenerative processes, such geriatric client. is not the case, as with macular degeneration. Eventually depth per- In the absence of adversity, the adult enjoys the daily challenges ception and peripheral vision are also affected. There may also be of living. If coping is altered for whatever reason, a risk for im- sensitivity to light, as with cataract formation. The nurse should be paired thought process exists. With the process of aging, there are alert for all etiologic components, especially the retinopathy asso- potential risks for impaired thought process. In addition, there ciated with diabetic alterations. may be potential risks for some regarding degenerative brain and central nervous system disorders, which also include impaired Hearing The adult has sensitivity to accurately discriminate 1600 thought processes. Two concerns for older adults related to al- different frequencies. There should be equal sensation of sounds for tered thought process are dementia and delirium or acute confu- the left and right ear. The Rinne test may be done to validate air and sional states. bone conduction via a tuning fork. The Weber test may be used to assess lateralization. Equilibrium assessment provides data regard- ing the vestibular branch. With time, the acuity of what is heard gradually diminishes, with APPLICABLE NURSING DIAGNOSES detection of high-pitched frequencies especially affected. The nurse should be concerned with a lack of response to loud noises and in- creased volume of speech and should be alert to cues of decreased Adaptive Capacity, Intracranial, Decreased hearing such as cupping of the hand on the “better” ear or leaning sideways to catch the conversation on the “better” side. DEFINITION Smell There may be a gradual deterioration in sensitivity for smell Intracranial fluid dynamic mechanisms that normally compensate after approximately age 60, although for the most part the sense of for increases in intracranial volumes are compromised, resulting in smell remains functional in the absence of organic disease. There repeated disproportionate increases in intracranial pressure (ICP) may be altered gastrointestinal enzyme production, which ulti- in

response to a variety of noxious and nonnoxious stimuli.2 mately interferes with usual perception of smells. Taste The ability to taste is well differentiated in adulthood. Sweet NANDA TAXONOMY: DOMAIN 9—COPING/STRESS and sour can be detected bilaterally. Concern may be raised if the TOLERANCE; CLASS 3—NEUROBEHAVIORAL STRESS client states the sense of taste has diminished or changed. There is a gradual loss of acuity in taste as aging occurs in later life. This is NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; due in part to decreased enzymatic production and utilization in di- CLASS I—NEUROLOGIC MANAGEMENT gestive processes. Over salting or spicing of foods may serve as a NOC: DOMAIN II—PHYSIOLOGIC HEALTH; clue to this loss of taste sensation. The use of dentures may also af- CLASS J—NEUROCOGNITIVE fect the sensation of taste and enjoyment of food. Touch The adult is able to discriminate on a wide range of tactile DEFINING CHARACTERISTICS2 stimuli, including pressure, temperature, texture, and pain or nox- ious components. With aging, there is a decrease in subcutaneous 1. Repeated increases in ICP of greater than 10 mm Hg for more fat, loss of skin turgor, increase in capillary fragility, and a decrease than 5 minutes following any of a variety of external stimuli in conduction of impulses. All these changes influence the sense of 2. Baseline ICP equal to or greater than 10 mm Hg touch, with a loss of acuity in aging. 3. Disproportionate increase in ICP following single environmen- tal or nursing maneuver stimulus Proprioception The adult is well coordinated and has a keen sense 4. Elevated P2 ICP waveform of perception of his or her body in space. There are multiple protec- 5. Volume pressure response test variation (volume : pressure ratio tive mechanisms that aid in maintaining balance. Typically, even 2, pressure-volume index 10) with eyes closed, the individual is able to stand and maintain balance. 6. Wide amplitude ICP waveform By now the tolerance and threshold one has for pain is well es- tablished. The individual has learned various ways to cope with RELATED FACTORS2 pain, thus may be equipped with a more stable base from which to respond. Paradoxically, the adult may also experience unresolved 1. Decreased cerebral perfusion pressure 50 to 60 mm Hg conflicts of previous development levels as well. For this reason, the 2. Sustained increase in ICP 10 to 15 mm Hg required change may be subject to associated changes as pain and 3. Systemic hypotension with intracranial hypertension its response affect the multiple demands of daily living by the adult. 4. Brain injuries The adult is equipped to solve problems and apply principles to everyday living. There is emphasis on seeking a mate for life who is RELATED CLINICAL CONCERNS able to satisfy basic companionship needs. There may be difficul- ties in accepting life’s challenges as parents or as adults juggling the 1. Head injury many necessary roles. There is, in later life, a gradual decline in 2. Cerebral ischemia problem-solving capacity, which may be exaggerated by illness. 3. Cranial tumors Allowing for potential decrease in bodily perception and func- 4. Hydrocephalus tioning with age must be considered. As assessment is carried out, 5. Cranial hematomas focus should be on risk factors such as chronic illness, financial 6. Arteriovenous formation deficits, resolution of ego integrity versus despair, and obvious eti- 7. Vasogenic or cytotoxic cerebral edema ologic components. The nurse should assist the patient to maintain 8. Hyperemia self-care, as the patient desires. 9. Obstruction of venous outflow Copyright © 2002 F.A. Davis Company 386 COGNITIVE-PERCEPTUAL PATTERN HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Protection This diagnosis is typically Capacity. However, the intracranial fluid volume associated with immune disorders or clotting and pressure are abnormal. disorders. However, maladaptive stress response and Ineffective Tissue Perfusion This diagnosis defines general neurosensory alterations are also associated a decrease in nutrition and oxygenation at the with Ineffective Protection. Decreased Intracranial cellular level due to a deficit in capillary blood Adaptive Capacity is a specific diagnosis related to supply and may be a companion diagnosis to intracranial fluid dynamic mechanisms. Decreased Intracranial Adaptive Capacity, Excess Fluid Volume This diagnosis refers to the depending on the cerebral perfusion pressure and overall fluid in the body. Body fluid may be the secondary physiologic cellular damage brought normal in Decreased Intracranial Adaptive on by the brain injury. EXPECTED OUTCOME TARGET DATES Will have ICP within normal range by [date]. Decreased Intracranial Adaptive Capacity is a life-threatening con- dition and should have target dates in terms of hours. After stabi- lization, the time frame may be moved to 48-hour increments. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Hyperventilate as necessary. Decreased PaCO2 leads to vasoconstriction and thus reduces cerebral blood flow.3 • Monitor arterial blood bases (ABGs). Maintain PaO2 80 mm Hyperventilation produces systemic alkalosis, which passes Hg; PaCO2 at 25–33 mm Hg. Avoid hypoxia. through the blood-brain barrier to buffer the cerebral acidosis created by lactic acid buildup.4 Hyperventilation can produce a paradoxical vasodilatation in areas of the brain.3,4 • Monitor cerebral blood flow and cerebral ischemia with xenon-enhanced computed tomography (CT) as needed. • Give IV Tham as ordered. Tham is a weak base that may produce a prolonged alkalization of the cerebrospinal fluid (CSF).4,5 • Monitor CSF for lactate and creatinine kinase BB bands. Reflects amount of brain tissue acidosis.6 • Monitor neurologic status: Glasgow Coma Scale for level of Routine neuroassessment can cause slight increases in intracranial consciousness, motor power, and general sensory examination pressure (ICP). as needed or at least every 8 h; pupillary size and response every hour; and cardiovascular and respiratory status every hour. • Monitor electrocardiogram (ECG). Watch for T-wave changes, Intracranial pathology is frequently associated with myocardial shortened P-R interval, prolonged Q-T interval, PVCs, ventricular dysfunction.7 ectopy, sinus bradycardia, and ventricular or supraventricular tachycardia. • Elevate head of bed 0–30 degrees. Keep head and neck in a Promotes venous drainage from the head.9 Some research indicates neutral position, or slightly extend head and neck. Do not good outcomes with head of bed flat.10 hyperextend head and neck. Do not turn head to right or left or place head and neck in a flexed position.8 Avoid hip flexion of more than 90 degrees. • Turn every 2 h. Have sufficient personnel to move the patient. Turning can cause increases in ICP by obstructing venous return Keep body and head in alignment. Turn slowly. May use from the brain.11 specialty beds and alternating pressure mattress. • Give medications for sedation (e.g., midazolam IV drip) and Relaxes and calms the patient. Keeps the patient from fighting or chemical paralysis (e.g., atracurium IV drip) as ordered. “bucking” the ventilator.12 Drugs need to have a short half-life so Lubricate eyes or tape shut. Provide comfort measures. Gently that neuroassessments, when done, are not affected.13 Stop drug touch hand or face. Talk quietly with the patient. approximately 1⁄2 hour before neuroassessment. Cover period with morphine. (continued) Copyright © 2002 F.A. Davis Company ADAPTIVE CAPACITY, INTRACRANIAL, DECREASED 387 (continued) ACTIONS/INTERVENTIONS RATIONALES • Prevent initiation of Valsalva maneuver. Any activity—conversation about the patient’s condition, either with the patient or at the bedside regarding the patient, coughing, sneezing, vomiting, bathing, giving medications, fever, pain, dressing change, agitation, spontaneous movement, etc.—can increase ICP.11,14–16 Light touch may decrease ICP.17 • Monitor fluid status. The patient should be normovolemic. Decreases cerebral intravascular fluid.18 Research discusses the use Sometimes fluids are restricted, and other times they are not. of hypertonic crystalloid solutions (NaCl 7.5 percent or 9 percent) Monitor intake and output and electrolytes. Monitor central with or without the addition of a colloid (dextran 70).19 venous pressure (CVP) (should be at least 6–8 mm Hg) or pulmonary wedge pressure. Fluid volume should provide sufficient mean arterial pressure (MAP) to support a cerebral perfusion pressure (CPP) of 60–70 mm Hg. (CPP  MAP  ICP) • Give diuretics as ordered (e.g., mannitol or furosemide). Removes water from cerebral tissues. Monitor serum osmolarity levels (should not exceed 320 mOsm). • Monitor prothrombin time (PT), partial thromboplastin time Normal values indicate a reduced risk of intracranial hemorrhage. (PTT), and platelet count. • Monitor ICP (goal  20 mm Hg) and CPP (CPP  MAP  ICP; Methods to measure ICP and CPP. Accurate monitoring of abnormal normal  80–100 mm Hg; range  50–150 mm Hg; goal ICP enables health care providers to aggressively treat patients and 60 mm Hg). CPP is an indirect index of cerebral bloodflow.12 results in improved patient outcomes.20 Transcranial doppler Use ventricular catheter, subarachnoid screw, epidural monitor, studies assess cerebral blood flow regionally and detect focal areas continuous jugular venous bulb oxygen saturation (SjbO2), of low flow or spasm.21 Along with arterial saturation, can assess arterial saturation of O2, pulse oximetry, transcranial doppler the relationship between the supply and use of O2 by the brain, studies, xenon-enhanced CT; cerebral oxygen extraction ratio providing early detection of cerebral ischemia.21 Cerebral oxygen (cO2ER  SaO2  SjbO2 / SaO2  100). extraction ratio is more indicative of oxygen supply and use by the brain.22,23 Refer to reference 23 for protocol used with cO2ER. • Monitor patency and sterility of monitoring device. Use closed Invasive techniques of monitoring hold inherent risk of cranial system. Change as per institution’s protocol. Never allow fluid infection.20 to backflow into cranial cavity. Do not use monitor (unless absolutely necessary) to obtain CSF. Assess insertion site when changing dressings. Keep site clean and dry. Monitor temperature, white blood count (WBC), and differential as per protocol. • Balance and recalibrate monitoring device as per institution protocol. • Give anticonvulsants as ordered. Prophylactic to prevent seizure activity, because seizures cause elevation in ICP and increase metabolic demand for oxygen and glucose.12 • Assist with barbiturate coma as ordered. Monitor the patient for Decreases metabolic activity of the brain. Also depresses cardiac decreased respirations and pneumonia. function, thereby decreasing cardiac output and blood pressure.12,18 • Give neuroprotective agents as ordered: Research in animals has shown that these drugs are effective in � Oxygen free radicals scavengers (antioxidants, e.g., PEG-SOD) reducing ischemic damage and preserving cell function.24–27 � Excitatory amino acid receptor (glutamate) antagonists Further research is needed to evaluate effects of drugs and drug (MK801 and D-CPP-ene) therapy in humans. � N-methyl D-aspartate (NMDA) antagonists or calcium channel blockers specific to neural tissue, e.g., nimodipine � High-dose synthetic steroids, e.g., methylprednisolone • Drain CSF from ventriculostomy based on ICP and cO2ER. Decreases ICP. • Suction cautiously as needed. Prophylactic use of lidocaine Suctioning can cause increase in ICP.12,14,28 HCl IV or endotracheally 5 min before suctioning has been recommended. Preoxygenate. Suction a maximum of 2 passes of 10 s, using less than 120 mm Hg of negative pressure. Use appropriate-size suction catheter. Oxygenate after suctioning with 100 percent oxygen. Caution in use of hyperventilation. Wait at least 5 min to allow ICP and CPP to return to normal before suctioning again. • Assist in hypothermia treatment as ordered. Best done within Decreases cerebral metabolic rate and ICP. 6 h of trauma for 48 h. Mild to moderate (89.6–93.2F). • Minimize environmental stimuli (light, sounds, and odors). Minimizes fluctuations in ICP and CPP.15 • Note ICP and CPP before and after activities. • Monitor response to nursing interventions. (continued) Copyright © 2002 F.A. Davis Company 388 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Coordinate and schedule interventions of all members of the Uncoordinated activities may dangerously increase ICP. health care team. • Avoid chilling when bathing. Do passive range of motion (ROM) Some research indicates bathing may be calming.16 exercises when bathing. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to altered intracranial pressure, Thorough evaluation for contributing factors allows for early especially positioning, treatments, medications, suctioning, detection of complications. ventilation, etc. • Carry out thorough neurologic assessment according to degree Deviations from norms will assist in differential workup and of stimulation and movement permitted per the infant’s or expedite treatment plan. child’s status. • Maintain head of bed 30 degrees, with head in line with Neutral body alignment will assist in stabilizing the intracranial body—ideally not positioned from side to side unless specified. adaptation. (Avoid use of pillows under head.) Recheck every 1 to 2 h. • Offer a calm, supportive environment with attention to safety Few stimuli will enhance the infant’s or child’s likelihood of

rest according to the infant’s or child’s needs. during acute phase, while safeguarding will minimize further injury. • Develop a daily plan of care that best matches the developmental Previous skills may be unable to be remastered or altered capacity of the infant or child, yet allows for possible regression. temporarily because of illness in the pediatric client. • Incorporate parental input in daily plan of care as appropriate. Family will feel valued, and their input will assist in providing some familiarity to the infant or child and lessen effects of multiple caregivers. • Offer time (30 min each shift and as needed) for parents to Assists in reducing anxiety, and offers cues regarding parental ventilate feelings regarding the infant’s or child’s status. concerns. • Provide adequate teaching regarding equipment, procedures, Knowledge allows for acceptance and understanding of the infant’s surgery, etc. or child’s status and power of masking unknown. • Offer gentle massage, and monitor carefully skin integrity and Likelihood of skin breakdown increases when repositioning is tissue perfusion, especially when condition lasts more than limited. 2 days. • Check for potential untoward effects of medications, and Likelihood of interaction increases with 3 or more medications, and exercise caution in appropriate dilution for IV administration. inappropriate administration may likewise cause side effects. • Maintain ongoing communication with the family to offer Trust in caregivers will be enhanced if the family can be kept updates on the infant’s or child’s condition. abreast of activities on ongoing basis. • Encourage the parents to bring the infant’s or child’s favorite Familiar favored objects offer a sense of security in otherwise blanket, small toy, or security object if possible. foreign setting, thereby reducing stress. • Arrange for appropriate follow-up, including home health, Appropriate referral will foster long-term continued regimen and physical therapy, or neurology, especially when there may be offer goals over time. a ventricular periteneal (V-P) shunt, for example. Women’s Health For Women’s Health, see Adult Health, except for the following interventions. ACTIONS/INTERVENTIONS RATIONALES ECLAMPSIA • Place on continuous intensive monitoring (cardiac and fetal). • Place in a darkened, quiet environment, to decrease external Reduction of external stimuli can reduce or prevent convulsions in stimuli. these patients. They need the reduction of light to lessen eye pain and headache. • Place padded tongue blade at head of bed. • Carefully monitor magnesium sulfate (MgSO4) levels, if appropriate, for therapeutic dose and/or toxicity. ONCE CONVULSION HAS BEEN CONTROLLED • Monitor fetal heart tone (FHT). • Assist the patient in orientation to time and place. Often lethargy and confusion are the result of MgSO4 therapy for eclampsia. (continued) Copyright © 2002 F.A. Davis Company ADAPTIVE CAPACITY, INTRACRANIAL, DECREASED 389 (continued) ACTIONS/INTERVENTIONS RATIONALES • Do not allow the patient to ambulate alone. Provide assistance. These patients feel out of control, lethargic, and confused and Provide bedside commode. cannot remember what has just been said to them as a result of both the convulsion and the medication. They need specific direction and a lot of support and understanding. NEWBORN • Carefully assess the newborn for cranial injury. • Carefully examine the infant’s skull. Note the anterior and posterior fontanels. Be especially alert for a bulging anterior fontanel indicative of: � Increased intracranial pressure � Major hemorrhage � Hydrocephalus Psychiatric Health The nursing actions for Psychiatric Health for this diagnosis are the same as the actions enumerated in the Adult Health section. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Maintain head in neutral position, even while the patient is Prevents increases in pressure from flexion or extension of the side-lying. head. NOTE: Nursing interventions found in the Adult Health section are appropriate to this age group. Cau- tion must be used because of the potential for problems regarding hydration, hypothermia, pupillary reaction, deficits related to eye surgery, and risk for sensory deprivation with decreased activity. Home Health See Adult Health care plan. If the patient with this diagnosis is in the home, professional home care will be required. Copyright © 2002 F.A. Davis Company 390 COGNITIVE-PERCEPTUAL PATTERN Adaptive Capacity, Intracranial, Decreased FLOWCHART EVALUATION: EXPECTED OUTCOME Is ICP within normal range? Yes No Record data, e.g., ICP has remained Reassess using initial assessment factors. within normal limits for 5 days, regardless of activities. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., ICP elevates and remains elevated for 6–8 min after each Did evaluation show another activity. Record CONTINUE and change problem had arisen? Yes target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CONFUSION, ACUTE AND CHRONIC 391 Confusion, Acute and Chronic 7. Fluctuation in sleep-wake cycle 8. Hallucination DEFINITIONS2 B. Chronic Confusion 1. Altered interpretation or response to stimuli Acute Confusion Abrupt onset of a cluster of global, transient 2. Clinical evidence of organic impairment changes and disturbances in attention, cognition, psychomotor ac- 3. Progressive and/or long-standing cognitive impairment tivity, level of consciousness, and/or sleep-wake cycle. 4. Altered personality Chronic Confusion Irreversible, long-standing and/or progres- 5. Impaired memory (short term and long term) sive deterioration of intellect and personality characterized by de- 6. Impaired socialization creased ability to interpret environmental stimuli and decreased 7. No change in level of consciousness capacity for intellectual thought processes and manifested by dis- turbances of memory. RELATED FACTORS2 A. Acute Confusion NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ 1. Over 60 years of age COGNITION; CLASS 4—COGNITION 2. Alcohol abuse 3. Delirium NIC: DOMAIN 4—SAFETY; CLASS V—RISK 4. Dementia MANAGEMENT 5. Drug abuse NOC: DOMAIN II—PHYSIOLOGIC HEALTH; B. Chronic Confusion CLASS J—NEUROCOGNITIVE 1. Multi-infarct dementia 2. Korsakoff’s psychosis 3. Head injury DEFINING CHARACTERISTICS2 4. Alzheimer’s disease 5. Cerebral vascular accident A. Acute Confusion 1. Lack of motivation to initiate and/or follow through with RELATED CLINICAL CONCERNS goal-directed or purposeful behavior 2. Fluctuation in psychomotor activity 1. Head injury 3. Misperception 2. Cerebral vascular accident 4. Fluctuation in cognition 3. Alzheimer’s disease 5. Increased agitation or restlessness 4. Chemical abuse 6. Fluctuation in level of consciousness 5. Dementia HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Sensory Perception An alteration in nonreality thinking. Other functioning is normal. one of the senses could create a short-term Confusion causes problems in both mental and confusion that is correctable. If a sensory deficit is physical functioning. found, the most correct diagnosis is Disturbed Impaired Memory This diagnosis is related to Sensory Perception. memory only. Other cognitive functioning may be Disturbed Thought Process The individual has a normal. problem with cognitive operation and engages in EXPECTED OUTCOMES TARGET DATES 1. If acute, will return to nonconfused state by [date] and/or For acute confusion, an appropriate target date would be 72 hours 2. If chronic, family will restate measures to work with confused after admission. Chronic confusion may be permanent, but the state by [date]. family should be able to learn appropriate intervention techniques within 72 hours. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Identify self and the patient by name at the beginning of each Memory loss necessitates frequent orientation to person, time, and interaction. environment. (continued) Copyright © 2002 F.A. Davis Company 392 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Speak slowly and in short, clear, concrete, simple sentences Allows time for information processing, and avoids use of complex and words. statements and abstract ideas. • Periodically orient and/or reorient the patient to the environment. Helps alleviate anxiety brought on by changing levels of orientation, and helps meet safety needs of the patient. • When the patient is delusional, focus on underlying feelings and Recognizing and/or acknowledging feelings may decrease the reinforce reality (have clocks, calendars, etc., on the wall). Do patient’s anxiety and give him or her a sense of being understood. not argue with the patient. Arguing may increase the patient’s anxiety and reinforce intensity delusions.29 • When hallucinations and/or illusions are present, reinforce False and/or distorted sensory experiences are common in reality and attempt to identify underlying feelings or confused states. To help decrease anxiety, focus on feelings environmental stimuli. underlying these experiences while calmly reinforcing reality.29 • If the patient becomes aggressive, focus on underlying feelings Focusing on feelings increases the patient’s feelings of being and attempt to refocus interaction on topics more acceptable understood, and discussing nonthreatening topics increases the and/or less threatening to the patient. patient’s sense of competency and self-esteem. • Keep the patient’s room well lighted. Maintain a calm Decreases possibility of environmental sensory misrepresentations, environment. and helps meet patient safety needs. Patients with confusion are experiencing increased levels of anxiety and can become physically and mentally exhausted. Promoting rest often means controlling environmental stimuli that contribute to the confusion. • Encourage the patient to wear and use personal devices These items increase accuracy of visual and auditory perceptions. (eyeglasses or hearing aids). • During abusive episodes, ignore insults and focus on underlying Projection of fear and anger onto persons in the environment is feelings. Set limits on behavior if physically abusive. common in confused states. Arguing with or becoming defensive escalates the situation and adds to the patient’s fear and anger. • Teach the family about the patient’s condition and how to Assists the family in understanding changes in the patient’s interact more effectively with the patient; i.e., provide ongoing orientation, cognition, and behavior. Increases the family’s sense orientation to surroundings and happenings within the family. of competency in relating to the patient. • Recognize family responses to the patient’s condition, and teach Family members often feel anxious and helpless about the patient’s about reasons for condition and how to respond during acute behavior. Teaching them reasons for the patient’s condition and episodes. how to respond decreases their anxiety and may help decrease the patient’s confusion. • Refer to psychiatric–mental health clinical nurse specialist (CNS). The psychiatric–mental health CNS has the expertise to collaborate Make other referrals to community agencies as needed, i.e., with the adult health nurse to plan nursing interventions for the Alzheimer’s support group, adult day care, meals-on-wheels, etc. patient that will help the patient and nursing staff deal with chronic confusion in the acute care setting. Child Health Although intended for population older than 60 years of age, confusion may occur in younger people as well, as a result of similar causes. Uncertainty may be greater regarding potential for recovery because of age, exact cause of problem, and so on. ACTIONS/INTERVENTIONS RATIONALES ACUTE • Monitor for potential contributory factors, especially as A thorough assessment offers the best basis for identification and applicable: treatment of confusion. � Prenatal influences, i.e., drugs, sepsis � Previous health status � Known conditions requiring treatment or not � Triggering event, trauma, surgery, emotional event � Daily routine or alterations • Determine with the parents previous patterns of development, Parents are best able to provide previous development capacity and develop daily plan of care within capacity offered by the cues within level of comfort for the infant or child, thus enhancing infant’s or child’s status. likelihood of sense of security for all. • Identify current plan of care to best suit the infant’s or child’s Best holistic plan of care reflects expertise of all who best know capacities with input from all members of health care team, and interact with the infant or child. especially the parents. • Offer treatment within developmentally appropriate framework In all situations there is greater likelihood of success in care when of the infant or child. the infant or child is approached from developmentally appropriate stance to afford a sense of security. (continued) Copyright © 2002 F.A. Davis Company CONFUSION, ACUTE AND CHRONIC 393 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide a safe and calm environment with stimuli best suited to An environment that is safe and developmentally appropriate the infant’s or child’s needs. provides freedom from injury while allowing the infant or child to recover. • Offer the parents realistic plans for the infant or child with Parents will better be able to trust and accept the infant’s or child’s frequent updates. status and caregivers when trusting relationships are based on communication that is honest and forthright. • Provide 30 min each shift for the parents to ventilate feelings Helps reduce anxiety, and offers cues to

parental concerns. about the infant or child. • Identify discharge and follow-up needs with attention to all Support for the parents upon the family’s return to home will help members of health team. maintain plan for care and thereby attain therapeutic goals. CHRONIC • Offer resources for support groups and advocacy interest Specific support groups will assist the parents in dealing with opportunities. situation represented by the infant’s or child’s status. • Explore specific patterns of daily care needs and how best to Realistic demands will best direct care according to time and offer care within domain of resources available. constraints. Note risk for Caregiver Role Strain due to demands over time. Women’s Health See nursing actions for Adult Health. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES ACUTE NOTE: Mental health clients at risk for this diagnosis include: Patients taking the following substances: Lithium, antianxiety agents, anticholinergics, phenothiazine, barbiturates, methyldopa, disulfiram, alcohol, cocaine, amphetamines, opiates, and hallucinogenics. Patients experiencing: Drug withdrawal, electroconvulsive therapy (ECT) treatments, dementia, dissociative disorders, mood disorders, and thought disorders, and elderly clients with acute infections such as urinary tract infections. • Place the client in an environment with appropriate stimuli. Increases patient safety and promotes orientation.30,31 Note level of stimulation and alterations in environmental stimuli here. For example, specific objects in the environment that stimulate illusions should be removed; appropriate lighting, clocks and calendars, and holiday decorations should be used. Refer to day, date, and other orienting information during each interaction with the client. • Assign the client room that provides opportunities for careful Promotes client safety and decreases environmental stimuli. High observation while not providing a chaotic environment. levels of stimuli can increase confusion and hyperactivity.32–34 • Place identifying information on the patient and the patient’s Promotes safety and orientation. room. Utilize the patient’s preferred name in each interaction. Note that name here. • Remove harmful objects from the environment. This could Protects the client from falls and accidental injury. Clients include objects in walkways, cords, belts, and raised bedrails or attempting to free themselves can fall or be injured on the other restraining devices. During periods of increased agitation, restraints.30 Promotes client safety. one-to-one observation should be instituted. • Assign primary care nurse each shift. Note those persons here. Promotes client orientation by providing familiar environment.31,32 • Communicate with the client using a moderate rate of speech Decreases ambiguity, prevents information overload, and provides and simple sentences without many questions. Allow time for the time necessary for the client to process information, which responding, and avoid indefinite pronouns. preserves self-esteem, decreases anxiety, and improves orientation.35 (continued) Copyright © 2002 F.A. Davis Company 394 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Observe every [number] minutes. Inform the client of this Promotes client safety. Provides opportunities to reorient the client schedule, and provide the client with written information as to here and now and to ensure client comfort.34 Promotes the necessary. Note information necessary for the client here. client’s sense of control. • Replace the use of physical restraints with one-to-one observation, comfort measures, recliners, appropriate physical Promotes safety and the client’s self-esteem by maintaining personal activity, visual barriers, secure unit, lower bed or bed on floor. control and dignity. Frequent use of restraints can encourage clients Note here those interventions specific to this client.30 to assume a passive approach to avoid further restraint or as an adaptation to daily use of restraints. At times, physical restraints may increase agitation.30,34,36 • If physical restraints are used, check circulation at least every Promotes client safety, sense of personal control, and 15 min, remove restraint one limb at a time at least every 2 h, self-esteem.31,37 Promotes physical comfort, which decreases and provide ROM, opportunities to void, nourishment, brief agitation. clear explanations about the purpose of the restraint, and information about when they will be removed during each interaction. • Utilize touch as appropriate to the client. Note the client’s Client’s touch preferences are very personal. Some clients may find preferences here. it comforting, whereas others may perceive it as an intrusion and respond with increased agitation.34 • Administer antipsychotic medication only if neurologic status Antipsychotic medications can increase confusion. These indicates that this will not increase confusion. medications can also produce orthostatic hypotension, increasing the client’s fall risk.30,33 • Provide daily routine that closely resembles the client’s normal Promotes orientation; increases the client’s sense of personal control. schedule. Note that schedule here. • Provide whatever aids the client needs to adequately perceive the Promotes orientation to the environment and sense of personal environment (hearing or vision). Note necessary aids here and control. location for storing when not in use by the client. • Assess mental status through normal interactions with the Repeated questioning can increase the client’s confusion, and client. Do not use formal mental status examinations unless inability to answer questions may have negative impact on absolutely necessary. Note method and schedule for assessment self-esteem.31,37 here. • Limit the client’s choices, and provide information or direction Increases orientation while preserving the client’s self-esteem. in brief, simple sentences. Note level of the client’s ability to Large amounts of information provided at one time can increase process information here, e.g., the client can choose between confusion and agitation.31,34 two items. Support optimal cognitive functioning by: (Note here those interventions to be used with this client.) � Responding to the client’s confused verbalizations (delusions, Increased anxiety can increase confusion and agitation.31,34 hallucinations, confabulations, illusions, etc.) in a calm manner � Utilizing refocusing and/or responding to the feelings Maintains self-esteem, relieves anxiety, and orients to present underlying the content to respond to confused verbalizations reality.38 � Utilizing “I” messages rather than arguments to reorient when Meets the client’s esteem needs by communicating respect while necessary. providing orientation.31,37,38 Promotes here-and-now orientation.31 � Providing clothing that is appropriate to time of day and situation, e.g., night clothes at night and street clothes during the day � Scheduling participation in groups that provide opportunities Promotes here-and-now orientation. Provides opportunities to to remember, review current events, discuss seasonal activities, maintain current cognitive skills.31,38 and socialize (Note here the schedule and appropriate groups for this client.) � Providing measures that promote rest and sleep. (Note here Inadequate sleep can increase confusion and disorientation.31 those measures that are specific for this client with schedule for implementation.) • Provide clear feedback on appropriate behavior. Refer to Risk for Positive reinforcement encourages behavior. Realistic goals increase Violence if the client is at risk for violent behavior toward self or opportunities for success, providing positive reinforcement and others. Assess expectations for being realistic with the client’s enhancing self-esteem. abilities. Note limits to be set here with specific consequences for unwanted behaviors and specific reinforcers for desired behaviors. • Provide support system with information about the client and Provides support system with positive coping strategies that how to best approach the client. Note here the information to enhance the client’s functioning. be provided and responsible person. (continued) Copyright © 2002 F.A. Davis Company CONFUSION, ACUTE AND CHRONIC 395 (continued) ACTIONS/INTERVENTIONS RATIONALES CHRONIC NOTE: Mental health clients at risk for this diagnosis include those with Alzheimer’s disease, Korsakoff’s psychosis, and AIDS dementia. In addition to those interventions for acute confusion, the following interventions are included. It is important to remember that the primary difference between these two diagnoses is the irreversibility of the cognitive deficits in this diagnosis. It is also important to assess the client for depression, because depression can appear as those illnesses that are related to this diagnosis, especially in elderly clients. • Maintain familiar environment: � Provide objects from the client’s home environment, to Promotes orientation while promoting sense of safety and include pictures, personal bedding, personal clothing, music, security.35 and other special objects with personal meaning. Note those objects important to the client here, with those nursing actions necessary to maintain the objects. � Label room with name in large letters and a familiar picture Maintains orientation while promoting a sense of personal control or item. by maintaining independence.31,37 � Provide same room for entire hospital stay. Assign primary Maintains orientation by providing continuity of surroundings and care personnel. Note those persons here. staff familiar with the client’s needs, perspective, and treatment plan. Excessive stimulation can exacerbate cognitive or behavioral problems. � Provide structured daily routines, and note the client’s Promotes orientation by providing familiarity.30,39 routine here. This should parallel prehospital routine as much as possible. • Provide opportunities for the client to be involved in Provide opportunities for clients to interact using current cognitive reminiscence, remotivation, current events, socialization, and skills, which helps decrease anxiety, maintain dignity, and prevent other groups as appropriate by providing the client with further deterioration and withdrawal.38 assistance needed to get to the groups. Note the client’s group schedule here, with the assistance needed from nursing staff. • Spend [number] min [number] times a day discussing the Promotes positive reorientation, maintains the client’s dignity, and client’s past experiences. This activity can be facilitated with promotes positive self-esteem. It is important to note that some music, family photographs, and other items that elicit memories. clients may have a great deal of difficulty coping with past Note the client’s response to this activity, and if it appears to experiences. If this process increases anxiety, the activity should be increase stress, discontinue. The process of this interaction is to discontinued, because high levels of anxiety can increase confusion. provide positive cognitive reframes of past experiences. • Identify and control underlying causes or triggers of increased Preserves the client’s dignity and sense of control.39 Each of these cognitive and behavioral problems. This could include limiting factors can decrease the client’s ability to cope. visitors or certain topics of conversation, increasing rest or providing rest periods during the day, and ensuring adequate hydration. Note the special adaptations here. • Utilize nonconfrontational approaches for dealing with behavior Maintains the client’s dignity, and recognizes the limitations of extremes. This could include changing the client’s context, cognitive abilities.39 responding to the feelings being expressed, or meeting comfort needs. Note here those responses that are most effective for the client. • Spend [number] minutes [number] times a day with the client Positive environmental cues from staff have been shown to doing (this should be some activity the client enjoys and that decrease problematic behaviors in these clients.40 provides an opportunity for success). • Spend [number] minutes [number] times a day involved in Increased physical activity decreases wandering behavior and [type] exercise with the client. (Choose exercise the client improves the client’s rest.36,40 enjoys and that involves large motor activity if at all possible.) • Retrieve and divert the client when wandering behavior presents Decreases the client’s wandering behaviors.40 risk or takes her or him into unobserved areas. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review pertinent laboratory work for possible imbalances. Acute confusion may be related to changes in electrolytes, glucose, or drug levels. (continued) Copyright © 2002 F.A. Davis Company 396 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Obtain medication list from the client or family of all prescribed Medications are a frequent precipitant for acute confusion, and over-the-counter (OTC) medications used by the client. especially in the very young or old. • Decrease extraneous audible-visual input. Provide low-stimuli Decreases sensory overload and need to cope with a complex and environment. noisy environment. • Provide orienting cues to the physical layout of the care site Promotes independence. (such as universal symbols for the bathroom, eating area, and the client’s room). • Provide personalized surroundings (familiar pictures, clothing, Promotes identification with self. or mementos). • Use client photograph to identify personal space. Increases connectedness with self. Provides sense of belonging. • Address the client by preferred name at each contact. Reinforces sense of self. • Introduce self by name at each contact. Provides sense of the familiar. • Arrange for the family or significant others to be available during Provides for familiar person in the care setting. periods of increased anxiety or agitation. • Use name and orienting cues in conversations. Enhances sense of self and connectedness. • Provide physical contact and/or comfort along with verbal Decreases anxiety generated when trying to cope with threatening interactions. environment. Assists the client in sorting out environment and setting. • Explore and explain briefly equipment used in care. Decreases fearfulness. • Disguise invasive equipment being used in

care. Prevents removal of needed equipment. • Use familiar objects for activities such as glasses or cups for Decreases complexity of coping with the unfamiliar. fluids rather than styrofoam cups or paper or plastic cartons. • Assign consistent caregivers. Provides sense of security. • Limit choices to two in situations where the client must make Decreases stress of too many choices. decisions such as dressing or eating. • Provide positive feedback for independent function. Promotes self-esteem. • Ensure quiet time or rest periods during the day. Decreases stress. • Approach and work with the client in an unhurried manner. Sense of urgency associated with speed perceived as threatening. • Provide information in simple sentences, and allow time for the Decreases complexity. client to process information. • If repetition is needed, repeat information in the exact manner Allows for processing of information. as originally stated. • Encourage participation in failure-free activities such as singing, Enhances self-esteem. exercise, or uncomplicated crafts. • Monitor mental status for changes at least daily and every shift in acute care setting. • Monitor for increased confusion related to new medication usage. Home Health NOTE: Onset of acute confusion may be an emergency requiring immediate referral for care. ACTIONS/INTERVENTIONS RATIONALES • Rule out possible causes of confusion: Understanding the cause of confusion determines the best � Drugs intervention. � Pain or discomfort � Full bladder � Bowel impaction � Infection (particularly pulmonary or urinary) � Alcohol or benzodiazepines withdrawal � Extreme anxiety • Offer explanation and support to the family members and Confusion is difficult to cope with at home and can be distressing caregivers. to family members. • Encourage the family members and caregivers to maximize Some effective communication can still occur if the client communication with the client during lucid intervals. Critical experiences lucid intervals. information should be exchanged during these times. • Help the family members and caregivers identify and cope with Understanding the cause of confusion determines the best impending death if confusion is occurring in the last hours of intervention. life. Terminal confusion, a condition common to impending death, is best treated with morphine, chlorpromazine, and scopolamine.41 (continued) Copyright © 2002 F.A. Davis Company CONFUSION, ACUTE AND CHRONIC 397 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying lifestyle changes that Home-based care requires involvement of the family. Acute may be required: confusion disrupts family schedules and role relationships. � Treatment or prevention of underlying problem (substance Adjustments in family activities and roles may be required. abuse, infection, pain, or nutritional deficits) � Providing for rest periods � Providing safe environment � Providing environmental cues to orient the patient, e.g., clocks or calendars � Provide assistive resources as required Decreased vision or hearing acuity may contribute to confusion. � Family response to changing behavior and mental status of the affected person • Assist the family to set criteria to help them determine when Provides the family with background knowledge to seek additional intervention is required, for example, change in appropriate assistance as need arises. baseline behavior. • Refer the patient to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the acutely confused person. Use of readily available resources is cost- effective. Copyright © 2002 F.A. Davis Company 398 COGNITIVE-PERCEPTUAL PATTERN Confusion, Acute and Chronic FLOWCHART EVALUATION: EXPECTED OUTCOME 1 Is the patient exhibiting signs and symptoms of confusion? Yes No Reassess using initial assessment factors. Record data, e.g., fully oriented  3. No hallucinations or delusions. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. Is diagnosis validated? Did evaluation show a new Yes No problem had developed? Record data, e.g., still disoriented to time and place. Hallucinations continue. Record CONTINUE and change target Yes No date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company CONFUSION, ACUTE AND CHRONIC 399 Confusion, Acute and Chronic FLOWCHART EVALUATION: EXPECTED OUTCOME 2 Can the family restate measures to assist the patient with confusion? Yes No Record data, e.g., wife, daughter, and son Reassess using initial assessment factors. restated and return-demonstrated all care measures with 100% accuracy. Arrangements completed for home health services. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., cannot restate ways to modify environment or work with father Did evaluation show another when agitated. Have not arranged for problem had arisen? Yes home health. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 400 COGNITIVE-PERCEPTUAL PATTERN Decisional Conflict (Specify) RELATED CLINICAL CONCERNS DEFINITION 1. Any surgery causing body image change 2. Any illness carrying a potential terminal prognosis The state of uncertainty about course of action to be taken when 3. Any chronic disease choice among competing actions involves risk, loss, or challenge to 4. Dementia personal life values.2 NANDA TAXONOMY: DOMAIN 10—LIFE PRINCIPLES; HAVE YOU SELECTED CLASS 3—VALUE/BELIEF/ACTION CONGRUENCE THE CORRECT DIAGNOSIS? NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING ASSISTANCE Anxiety Anxiety is considered to be a feeling of threat that may not be known by NOC: DOMAIN II—PHYSIOLOGIC HEALTH; the person as a specific causative factor. In CLASS J—NEUROCOGNITIVE Decisional Conflict, the patient knows the options but cannot decide between specifics. DEFINING CHARACTERISTICS2 Deficient Knowledge In Deficient Knowledge, the client does not have the 1. Verbalization of undesired consequences of alternative actions information to make a decision. In Decisional being considered Conflict, the information is known. 2. Verbalized uncertainty about choices Ineffective Individual Coping This diagnosis 3. Vacillation between alternative choices is closely related in that adaptive behavior and 4. Delayed decision making problem-solving abilities are not able to meet 5. Verbalized feeling of distress while attempting a decision the demands of the client’s needs. Ineffective 6. Self-focusing Individual Coping and Decisional Conflict 7. Physical signs of distress or tension (e.g., increased heart rate, may very well be companion diagnoses. increased muscle tension, restlessness) 8. Questioning personal values and beliefs while attempting a de- cision EXPECTED OUTCOME RELATED FACTORS2 Will verbalize at least one concrete personal decision by [date]. 1. Support system deficit 2. Perceived threat to value system TARGET DATES 3. Multiple or divergent sources of information 4. Lack of relevant information Value clarification, belief examination, and learning decision- 5. Unclear personal values or beliefs making processes will require a considerable length of time and will 6. Lack of experience or presence of interference with decision require much support. Therefore, target dates in increments of making weeks would be most appropriate. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Instruct the patient in stress-reduction techniques as needed. Reduces anxiety, enabling the patient to better process problems. Have the patient return-demonstrate specific techniques at least daily. • Assist the patient to focus on problem-solving processes. Help Assists the patient to learn to use the problem-solving process. the patient verbalize alternatives and advantages and disadvantages of solutions. Help the patient realistically appraise situations and set realistic short-term objectives daily. • Support the patient’s values as necessary. Do not be judgmental Helps the patient focus on what is important to self in decision when interacting with the patient. Help the patient to clarify making rather than being concerned about pleasing others. values and beliefs as needed. • Assist the patient to seek, find, and interpret relevant information Assists the patient to explore alternatives; coordinates care of the about problem; refer the patient to community resources for patient. support. • Refer to psychiatric nurse clinician as needed. A nurse specialist may be better able to help the patient focus on the underlying process. Copyright © 2002 F.A. Davis Company DECISIONAL CONFLICT (SPECIFY) 401 Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine who will intervene on behalf of the infant or child: For legal and ethical reasons, it is essential to clarify when the parents or appointed legal guardian. parent(s) are unable to assume the parental role and obligations and to make this fact known to all involved in the child’s care. It is likewise essential for all caregivers to know who the legal guardian or spokesperson is. • In instances of conflicting decision makers, ensure that the Irrespective of conflicts in decision making, the infant or child is child’s rights are protected according to legal statutes. entitled to appropriate care. In extreme cases of conflict, a state or local judge may appoint guardians or foster parents to assume decision making regarding health matters. In other instances, e.g., withholding suggested treatment because of religious beliefs, individual statutes and precedents must be sought by the parties involved. • Ensure that appropriate documentation is carried out according Legal documentation according to health care decisions and related to situational needs. matters is to be carried out as standard care, with attention to the mandates of the institution regarding appropriate paper forms to complete. • Although the child may be ill equipped or unable to participate Early involvement in decision making fosters safe support for the fully in decision making, encourage developmentally appropriate child, thereby increasing the likelihood of learning effective coping components for care to assist the child in learning decision behaviors. Will also empower the child and foster a positive making. self-image. • Be certain that choices or options indeed exist when the child is Preferences and individualization will be realistically valued when allowed to exercise decision making. there is choice or options in the care plan. It is unethical to indicate there are choices when none exist, e.g., medication cannot be given by any other route but intramuscular. • Provide behavioral reinforcement that best fosters learning with Appropriate reinforcement will serve to enhance learning and assist appropriate follow-up when the child is involved in decisional the patient in growth in decision making. conflict. • Consider potential long-term residual or subsequent effects Decision making often has far-reaching effects, e.g., in early related to specific decisional conflict for the child or family. childhood, values of a lifetime are formulated. Appropriate regard to this fact should guide all involved in this aspect of child-rearing and supportive aspects of health care. Women’s Health Unwanted Pregnancy ACTIONS/INTERVENTIONS RATIONALES • Provide an atmosphere that encourages the patient to view her Provides information that allows the patient to make an informed options in the event of an unwanted pregnancy. Assure the choice. patient of confidentiality. • Give clear, concise, complete information to the patient, describing the choices available to her: � Carrying the pregnancy and keeping the infant � Adoption of the infant � Abortion • Discuss with the patient the advantages and disadvantages of each option. • Encourage the patient to discuss beliefs and practices in a nonthreatening atmosphere, and include significant others in conversation and decision as the patient desires. • Refer the patient to proper agency for guidance and treatment. • Discuss and review with the patient the different methods of Provides information and support to assist the patient in planning birth control. future pregnancies. • Assess the patient’s ability to correctly use the different methods of birth control. • Provide factual information, listing the advantages and disadvantages of each method. • Provide the patient information on obtaining her method of choice. • Explore with the patient and significant other their views on children and family. Copyright © 2002 F.A. Davis Company 402 COGNITIVE-PERCEPTUAL PATTERN Women’s Health Less-Than-Perfect Infant NOTE: Families faced with the birth of a child with congenital anomalies or developmental defects ex- perience decisional conflict and great confusion about choices that need to be made. Often there is a sense of urgency, because decisions need to be made quickly to save the life of the infant. Many times the infant was delivered by cesarean section, and it is the mother’s partner who, alone, must often make crucial decisions that could affect the family and the life of the infant. Parents not only experience con- fusion, but fear, guilt, helplessness, and inadequacy as parents. ACTIONS/INTERVENTIONS RATIONALES • Provide accurate information to the parents as soon as possible. Provides information and supportive environment that helps

the parents make decisions.42,43 STILLBORN OR FETAL DEMISE • Let the parents see and hold the infant if at all possible. Promotes bonding and provides comfort for both the parents and infant. • Support the parents in their grieving process for the loss of the perfect infant and perhaps the death of the infant.44,45 • Keep the parents informed continuously, and encourage the health care team to talk to them often. • Contact significant persons, of the parents’ choice, who can come and be of support to them.46 • Give the parents a private place to be with their support persons. • Encourage the parents to visit the infant in the neonatal intensive care unit (NICU) as often as possible. • Collaborate with NICU staff to plan time for the mother and the infant activities together as much as possible. • Refer to support groups and agencies as needed for follow-up Support is essential in resolving decisional conflict. care when leaving hospital.47,48 Psychiatric Health NOTE: The client who is experiencing a decisional conflict is faced with confusion about alternative solutions. When assisting these clients, the nurse should be careful not to connote the client’s confu- sion negatively. Various authors49–51 have supported the positive role confusion plays in the change process. Erickson49 frequently encouraged confusion as a way to distract the conscious mind and al- low the unconscious to develop solutions. It is from this theoretical base that the following interven- tions are developed. ACTIONS/INTERVENTIONS RATIONALES • Assure the client that the difficulty he or she is experiencing in Promotes positive orientation, self-worth, and hope. decision making is positive in that it has placed him or her in a position to look for new creative solutions. If he or she were not experiencing this difficulty, he or she might be tempted to remain in the same old problem solution set. • Assist the client in reducing the pressure of time on making a decision. • Have the client explain the time he or she has given himself or Provides time to develop alternative problem solutions, and herself to make a decision. Asking the client the following decreases stress on the client. question may assist in this process: “What is the worst that will happen if a decision is not made right now?” • Sit with the client for 30 min twice per day to discuss the Aids in understanding the client’s perception of the situation. information and perceptions she or he has regarding the current situation and possible solutions. As the client explores the situation, the remaining interventions can be added to these discussions. • Have the client explore feelings related to the choices and the The client’s cognitive style and feelings about the situation affect information related to the choices. This process may extend his or her appraisal of both the situation and possible solutions.52 over several days. The client may be reluctant to verbalize negative feelings related to certain choices if a trusting relationship has not yet been developed with the nurse. (continued) Copyright © 2002 F.A. Davis Company DECISIONAL CONFLICT (SPECIFY) 403 (continued) ACTIONS/INTERVENTIONS RATIONALES • Have the client discuss how significant others think and feel Support system involvement increases the probability of positive about the various choices. Have the client evaluate the impact outcomes. of the feelings of significant others on his or her decision-making process. • Have the client fantasize an ideal choice. Accesses creative problem solutions that bypass the client’s self- imposed limits. • Have the client construct a list of solutions (at least 20) that would produce the ideal choice. (These solutions are not to be evaluated at this time.) Encourage the client to develop some unrealistic solutions. This may be promoted by asking the client what he or she might tell a friend to do in this situation or by having the client generate three magic-wish solutions, e.g., “If you had a magic wand, what would you do to resolve this situation?” • Sort through developed list with the client generating solutions from the ones listed. At this time, the client can begin to combine and eliminate ideas after evaluation. Carefully evaluate each solution before it is eliminated. What appears to be a bizarre solution can become useful when altered or combined with another idea. • As each idea is evaluated, provide all information necessary to Aids in assessing the client’s commitment to each possible solution. evaluate the idea. • Explore the client’s thoughts and feelings about each idea. • Remind the client that there are no perfect answers and that Promotes positive orientation, self-worth, and hope for the future. each of us makes the best choice that can be made at the time. • Remind the client that if a choice that is made does not resolve Promotes positive orientation. the problem, alternative solutions can then be tried. • Remind the client that a solution that does not work provides more information about the problem that can be used in developing future solutions. • Meet with the client and support system to allow the support Support system involvement increases the probability of positive system to be a part of the decision-making process if this is outcome. appropriate. • Discuss with the client and support system any secondary gains Assesses for positive reinforcement for not resolving problem. from not making a decision. • Once a decision is made, have the client develop a behavioral Having a plan to cope with the anticipated situations promotes a plan for implementation. perception of greater control over future situations and increases the probability of the client’s enacting new coping behaviors. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the patient prior examples of Decisional Conflict Emphasizes ability to problem solve, and reinforces successes. and their outcomes. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family measures to decrease Decisional Appropriate knowledge and values clarification between the client Conflict: and family will reduce conflict. � Providing appropriate health information � Joining a support group � Clarifying values � Performing stress reduction activities � Seeking spiritual or legal assistance as needed � Identifying useful sources of information (continued) Copyright © 2002 F.A. Davis Company 404 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying risk factors pertinent Early identification of risk factors provides opportunity for early to the situation: intervention. � Lack of knowledge � Developmental or situational crisis � Role confusion � Excess stress � Excess stimuli • Answer questions about a terminal diagnosis and prognosis with Develops trusting relationship, and helps clients make honesty and sensitivity. well-informed decisions. • Consult with or refer the patient to appropriate assistive Use of the network of existing community services provides for resources as indicated. effective utilization of resources. Copyright © 2002 F.A. Davis Company DECISIONAL CONFLICT (SPECIFY) 405 Decisional Conflict (Specify) FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient identify at least one decision that has been made and implemented? Yes No Record data, e.g., has decided to go to Reassess using initial assessment factors. night school to complete high school diploma; has completed application process and been admitted. Record RESOLVED (may wish to use CONTINUE until the client has become more comfortable and consistent in decision making). Delete nursing No Is diagnosis validated? diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has sought information regarding night school but has taken no Did evaluation show another further action. Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 406 COGNITIVE-PERCEPTUAL PATTERN Environmental Interpretation Syndrome, 3. Dementia (e.g., Alzheimer’s disease, multi-infarct dementia, Pick’s disease, AIDS, alcoholism, Parkinson’s disease) Impaired 4. Alcoholism 5. Parkinson’s disease DEFINITION Consistent lack of orientation to person, place, time, or circum- RELATED CLINICAL CONCERNS stances over more than 3 to 6 months, necessitating a protective en- vironment.2 See Related Factors. NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ HAVE YOU SELECTED COGNITION; CLASS 2—ORIENTATION THE CORRECT DIAGNOSIS? NIC: DOMAIN 4—SAFETY; CLASS V—RISK MANAGEMENT There are several diagnoses that interface with this diagnosis, e.g., Impaired Memory, NOC: DOMAIN II—PHYSIOLOGIC HEALTH; Disturbed Thought Process, or Confusion. CLASS J—NEUROCOGNITION This diagnosis refers to a long-term problem (3 to 6 months) that results in the patient’s DEFINING CHARACTERISTICS2 having to be admitted to a protective environment. This diagnosis predominantly 1. Chronic confusional states relates to an end result of the other 2. Consistent disorientation in known and unknown environments diagnoses. 3. Loss of occupation or social functioning from memory decline 4. Slow in responding to questions 5. Inability to follow simple direction, instructions 6. Inability to concentrate EXPECTED OUTCOME 7. Inability to reason Will have decreased episodes of environmental confusion by [date]. RELATED FACTORS2 TARGET DATES 1. Depression This is a long-term diagnosis, so an appropriate target date would 2. Huntington’s disease be expressed in terms of weeks or months. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: These actions/interventions and rationales are essentially the same as those for Chronic Confusion. ACTIONS/INTERVENTIONS RATIONALES • Identify self and the patient by name at each interaction. Short-term memory loss necessitates frequent orientation to person, time, and environment. • Speak slowly and clearly in short, simple words and sentences. Allows time for information processing, and avoids use of complex statements and abstract ideas. • When the patient is delusional, focus on underlying feelings Recognizing and acknowledging feelings may decrease the client’s and reinforce reality (have clocks, calendars, etc. on the wall); anxiety and give a sense of being understood. Arguing may increase do not argue with the patient. the patient’s anxiety and reinforce intensity delusions.53 • If the patient becomes aggressive, focus on underlying feelings Focusing on feelings increases the patient’s feelings of being and attempt to refocus interaction on topics more acceptable understood, and discussing nonthreatening topics increases the and/or less threatening to the patient. patient’s sense of competency and self-esteem. • Keep the patient’s room well lighted. Maintain a calm Decreases possibility of environmental sensory misrepresentations, environment. and helps meet patient safety needs. • Teach the family about the patient’s condition and how to Assists the family in understanding changes in the patient’s interact more effectively with the patient; i.e., provide ongoing orientation, cognition, and behavior. Increases the family’s sense of orientation to surroundings and happenings within the family. competency in relating to the patient. • Refer to psychiatric–mental health CNS. Make other referrals to The psychiatric-mental health CNS has the expertise to collaborate community agencies as needed, i.e., Alzheimer’s support group, with the adult health nurse to plan nursing interventions for the adult day care, meals-on-wheels, etc. patient that will help the patient and nursing staff deal with chronic confusion in the acute care setting. Copyright © 2002 F.A. Davis Company ENVIRONMENTAL INTERPRETATION SYNDROME, IMPAIRED 407 Child Health This diagnosis may present in children also; if so, the same basic plan of care as that of adults should be implemented, with attention to safe, developmentally appropriate interventions. ACTIONS/INTERVENTIONS RATIONALES • Monitor for parental-infant reciprocity to determine nature of Reciprocity will offer cues as to what match does or does not exist parent-infant or -child relationship. in the relationship. • When there may be a genetic concern, offer appropriate When a genetic component exists, there is an obligation for present counseling. and futuristic planning by all involved. • Offer 30 min each shift for the parents to ventilate specific Offers reduction in anxiety, plus an opportunity to note parental concerns regarding the infant or child. concerns. Women’s Health See Adult Health nursing actions. Psychiatric Health Mental health clients who demonstrate this syndrome would include those with depression, alcoholism, and chronic thought disorders. ACTIONS/INTERVENTIONS RATIONALES • Monitor the client’s level of anxiety and refer to Anxiety (Chap. 8) Increased anxiety can negatively impact memory and orientation for detailed interventions related to this diagnosis. and contribute to further deficits. • Place the client in an environment with appropriate stimuli. Increases patient safety and promotes orientation. Note level of stimulation and alterations in environmental stimuli here; i.e., specific objects in the environment that stimulate illusions should be removed, and appropriate lighting, clocks, calendars, and holiday decorations should be provided. Refer to day, date, and other

orientating information during each interaction with the client. • Place identifying information on the patient and the patient’s Provides safety and promotes orientation. room. Utilize the client’s preferred name in each interaction. Note that name here. • Remove harmful objects from the environment. This could Protects the client from falls and accidental injury. include objects in walkways, cords, belts, and raised bedrails or other restraining devices. Note here special precautions for this client. • Assign primary care nurse each shift. Note those persons here. Promotes client orientation by providing familiar environment. • Observe every [number] minutes. Inform the client of this Promotes client safety. Provides opportunities to reorient the client schedule, and provide the client with written information as to here and now and to ensure client comfort. Promotes the client’s necessary. Note information necessary for the client here. If the sense of control. client is depressed, this observation may be increased because of increased risk for self-harm. Refer to Risk for Violence (Chap. 9) for specific interventions. • Provide daily routine that closely resembles the client’s normal Promotes orientation, and increases the client’s sense of personal schedule. Note that schedule here. control and orientation. • Assess mental status through normal interactions with the client. Repeated questioning can increase the client’s confusion, and Do not use formal mental status examinations unless absolutely inability to answer questions may have negative impact on necessary. Note here method and schedule for assessment. self-esteem. • Limit the client’s choices, and provide information or direction High levels of stimulation can increase confusion, and inability to in brief, simple sentences. Note here the level of the client’s make choices may have negative impact on the client’s self-esteem. ability to process information, e.g., the client can choose between two items. • Keep initial interactions short but frequent. Speak to the client Too much information can increase the client’s confusion and in brief, clear sentences. Note frequency and length of disorganization. interactions here. • Utilize “I” messages, rather than argument, to reorient when Meets the client’s esteem needs by communicating respect while necessary. providing orientation. Promotes here-and-now orientation. • Respond to confused verbalizations by responding to the feelings Maintains self-esteem, relieves anxiety, and orients to present being expressed. reality. (continued) Copyright © 2002 F.A. Davis Company 408 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • When the client’s ability to tolerate more complex situations Promotes here-and-now orientation. Provides opportunities to increases, schedule his or her participation in groups that maintain current cognitive skills. provide opportunities to remember, review current events, discuss seasonal activities, and socialize. Note here the schedule and appropriate groups for this client. • Provide clear feedback on appropriate behavior. Set behavior Positive reinforcement encourages behavior. Realistic goals increase goals that the client can achieve. Note here those behaviors that opportunities for success, providing positive reinforcement and are to be rewarded and the rewards that are to be given. enhancing self-esteem. • Spend [number] minutes [number] times a day involved in Improves rest and increases natural endorphins. exercise with the client. (Choose exercise the client enjoys and that involves large motor activity if at all possible.) Note the specific activity here. • Spend [number] minutes [number] times per week providing Family and client involvement enhances effectiveness of information to the client’s support system. Note specific intervention and promotes community support. information to be provided and person responsible for this activity here. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Review mental status examination to identify areas of strengths Depending on examination used, may indicate the client’s ability to and needs. read, interpret symbols, or process simple versus complex instructions. • Survey current environment for potential unsafe areas. Correcting unsafe areas decreases potential for client injury. • Adapt environment to decrease risk for injury, e.g., access to exits, thermal injury potential, or ingestion of harmful substances. • Instruct the caregiver in environmental adaptations to provide protective environment. • Use labeling or pictorial symbols to indicate specific areas or Assists the client to interpret environment. conveniences (such as universal symbols for food or restrooms or pictures to indicate the client’s room). • Ensure identification of the client (ID bracelet or necklace). Provides means of identification in the event the client leaves the care setting. • Provide conversational cues to person, place, and time. Presents information in a nonquizzing, nonthreatening manner. Home Health ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in identifying lifestyle changes that Home-based care requires involvement of the family. Impaired may be required: interpretation of the environment disrupts family schedules and � Provide consistent care provider. role relationships. Adjustments in family activities and roles may � Provide for consistent daily schedule with structured activities. be required. � Have the client wear identification bracelet; put name in clothing. � Provide safe environment. � Provide environmental cues to orient the patient, e.g., clocks or calendars. � Provide assistive resources as required. Decreased vision or hearing acuity may contribute to confusion. � Monitor family response to changing behavior and mental status of the affected person. • Assist the family to set criteria to help them determine when Provides the family with background knowledge to seek additional intervention is required; for example, help them to appropriate assistance as need arises. recognize signals indicating a change in their ability to maintain a safe environment. • Offer support to the caregivers and family members: Promotes adaptive coping. � Teaching about management of behavior � Self-care strategies � Community resources • Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the family member with Impaired Environmental Interpretive Syndrome. Copyright © 2002 F.A. Davis Company ENVIRONMENTAL INTERPRETATION SYNDROME, IMPAIRED 409 Environmental Interpretation Syndrome, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient had a decreased number of environmental confusion episodes? Yes No Record data, e.g., can follow Reassess using initial assessment factors. simple directions. States in nursing homes 8 times out of 10. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still disoriented  3. Slow in response to questions. Mental Did evaluation show another status examination abnormal. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 410 COGNITIVE-PERCEPTUAL PATTERN Knowledge, Deficient (Specify) 3. Inaccurate follow-through of instruction 4. Inaccurate performance of test DEFINITION RELATED FACTORS2 Absence or deficiency of cognitive information related to specific topic.2 1. Cognitive limitation 2. Information misinterpretation NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ 3. Lack of exposure COGNITION; CLASS 4—COGNITION 4. Lack of interest in learning 5. Lack of recall NIC: DOMAIN 3—BEHAVIORAL; CLASS S—PATIENT 6. Unfamiliarity with information resources EDUCATION NOC: DOMAIN IV—HEALTH KNOWLEDGE AND RELATED CLINICAL CONCERNS BEHAVIOR; CLASS S—HEALTH KNOWLEDGE 1. Any diagnosis that is entirely new to the patient 2. Mental retardation DEFINING CHARACTERISTICS2 3. Post head injury 4. Depression 1. Verbalization of the problem 5. Dementia 2. Inappropriate or exaggerated behaviors, for example, hysterical, hostile, agitated, or apathetic HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Noncompliance In Noncompliance, the patient Powerlessness This diagnosis would be reflected by can return-demonstrate skills accurately or statements such as “How will this help?” “I have no verbalize the regimen needed, but does not follow control over this,” “I have to rely on others” rather through on the care. than statements related to “I don’t really understand,” Disturbed Thought Process This diagnosis would “I’m not really sure how,” or “Is this right?” be evident by lack of immediate recall on return- Ineffective Health Maintenance Ineffective Health demonstration rather than inaccurate or limited Maintenance may include Deficient Knowledge, demonstration and recall. but is broader in scope and includes such aspects as limited resources and mobility factors. EXPECTED OUTCOME TARGET DATES Will return-demonstrate [specific knowledge deficit activity] by Individual learning curves vary significantly. A target date ranging [date]. from 3 to 7 days could be appropriate based on the individual’s pre- vious experience with this material, education level, potential for learning, and energy level. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Contract with the patient regarding what the patient wants and Incorporates the patient into learning process, and provides needs to learn. Be sure to include a time frame in the contract. additional motivation for resolving deficit; allows assessment of the Have the patient sign contract to ensure patient consent for patient’s readiness to learn. Improves learning because it is based teaching. Review the patient’s and family’s current level of on exactly where the patient and family are in their knowledge and knowledge regarding this illness, hospitalization, and cultural avoids needless repetition. and value beliefs. • Design teaching plan specific to the patient’s deficit area, e.g., Provides new knowledge based on the patient’s perceived needs. self-administration of medication, and specific to the patient’s Individuals learn in their own way and in their own time frame. level of education, e.g., eighth-grade reading level. Include Motivates learning and provides support and reinforcement for significant others in teaching sessions. Be sure plan includes learning. content, objectives, methods, and evaluation. (continued) Copyright © 2002 F.A. Davis Company KNOWLEDGE, DEFICIENT (SPECIFY) 411 (continued) ACTIONS/INTERVENTIONS RATIONALES • Explain each procedure as it is being done, and give the Incorporates another teaching method; reduces anxiety, thus rationale for procedure and the patient’s role. promoting learning. • Teach only absolutely relevant information first. The patient will remember initial information more than subsequent information. Avoids overwhelming the patient with information. • Provide positive reinforcement as often as possible for the Reinforces learning achieved and promotes positive orientation. patient’s progress. • Design teaching to stimulate as many of the patient’s senses as Enhances learning, and provides mechanism to evaluate learning possible, e.g., visuals, audio, touch, or smell. Have the patient and teaching effectiveness and allow clarification of any return-demonstrate any psychomotor activities. misunderstandings. • Have the patient restate, in his or her own words, cognitive Repeated practice of a behavior internalizes and personalizes the materials during teaching session. Have repeat on each behavior.53 subsequent day until discharge. • Provide quiet, well-lighted, temperature-controlled teaching Limits distractions. environment during teaching session. • Ensure that basic needs are taken care of before and Prevents distractions during teaching session due to basic needs immediately after teaching sessions: not being met. � Food and fluids � Toileting � Pain relief • Pace teaching according to the patient’s rate of learning and Considers the patient’s learning style and ability to process new preference during teaching session. information. • Encourage the patient’s verbalization of anxiety, concern, etc. Considers the patient’s input into plan of teaching. Increases about self-care. Listen carefully. Redesign plan to incorporate likelihood of the patient’s retaining and using information. the patient’s concerns as needed. Expressing fear and anxiety helps reduce their levels and provides a means by which possible resources can be explored for dealing with the patient’s health care issues. • Incorporate into teaching plans, in addition to specifics (provide Provides foundational knowledge on which to build more specific written information to reinforce verbal teaching): information. � Normal body functioning � Signs and symptoms of altered functioning � Diet (food and fluid) � Exercise and activity � Growth and development � Self-examination � Impact of environment, stress, and change in lifestyle on health • After first teaching session, start each teaching session with Reinforces what is known. Builds new information on previous revalidation of the previous session. End each session with a knowledge, and organizes new knowledge for the patient. summary. • Collaborate with and refer the patient to appropriate assistive Coordinates team approach to health and provides means to follow resources. up and reinforce learning. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine whether there are ambiguities in the minds of the Clarification and verification will ensure a greater likelihood of parents or child. understanding and valuing aspects critical to patient teaching. • Identify the learning capacity for the patient and family. Realistic capacity for learning should be a primary factor in patient teaching, because it serves as one major parameter in expectations of learning. • Determine the scope and appropriate presentation for the patient Developmental needs of all involved will best serve as an essential and family based on previous

actions, plus developmental crises framework for teaching the patient and family. Potentials and for each and all—do not overwhelm the patient. capacity for use of all the sensory-perceptual aspects of cognition should be explored and used to ensure the best opportunity for effective teaching. • Evaluate appropriately the effectiveness of the teaching-learning Evaluation is an indicator of both teaching effectiveness and experience by: learning. It serves as another essential aspect of patient teaching � Brief verbal discourse to provide concrete data with the appropriate focus on individualization by pointing out � Written examination in brief to show progress areas needing reteaching. (continued) Copyright © 2002 F.A. Davis Company 412 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Observation of skills critical for care, e.g., change of dressing according to sterile technique � Allowing the child to perform skills in general fashion with use of dolls Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Teach normal physiologic changes the new mother can expect Provides information to assist new mothers in postpartum post partum: adaptation. � Lochia flow (1) Normal: Rubra 1–3 days; serosa 3–10 days; alba 10–14 days (2) Abnormal: Bright red blood and clots with firm uterus, foul odor, pain, fever, or persistent lochia serosa or pink to red discharge after 2 wk � Breast changes (1) Breastfeeding: Engorgement, comfort measures, clothing, positions for mother and infant comfort and hygiene (also see actions for the Nutrition diagnoses in Chap. 3) (2) Non-breastfeeding: Suppression of lactation (medications, clothing such as tight-fitting bra, and comfort measures); importance of holding the baby while bottle-feeding (do not prop bottle and do burp the baby often); formulas (different kinds and preparation) � Perineum and rectum: Episiotomy, hemorrhoids, hygiene, medications, and comfort measures • Demonstrate infant care to new parents: Assists new parents in adapting to parenting role. Allows the � Bathing parents to practice new skills in a nonthreatening environment and � Feeding seek clarification from an informed source. � Cord care � Holding, carrying, etc. � Safety � Sleep-wake states of the infant • Provide quiet, supportive atmosphere for interaction with the Promotes positive learning experience for the mother, father, and infant to allow the parent to: baby. � Become acquainted with infant � Practice caretaking activities such as breastfeeding or formula feeding � Begin integration of the infant into the family • Discuss infant care, taking into consideration age and cultural differences of the parents: � Teenagers: Involve significant others. Have the mother return-demonstrate infant care. Refer to support systems such as Young Parent Services and church groups. � First-time older mothers: Allow verbalization of fears. Involve significant others. Provide encouragement. • Adjust teaching to take into consideration different cultural caretaking activities, such as preventing the evil eye in the Hispanic culture, or the mother not holding the baby for several days immediately after birth in some Far Eastern Indian cultures. • Demonstrate newborn skills to the parents. Utilize different assessment skills to teach the parents about their newborn’s capabilities—gestational age assessment, physical examination of newborn, or Brazelton Neonatal Assessment Scale. • Encourage the parents to hold and talk to the newborn. Helps the parents gain confidence when caring for the newborn. Provides opportunity for nurse to teach and reinforce teaching. (continued) Copyright © 2002 F.A. Davis Company KNOWLEDGE, DEFICIENT (SPECIFY) 413 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss different methods of birth control and the advantages Informs the new mother (parents) of choices in birth control and disadvantages of each method: methods, and gives them the opportunity to ask questions. � Chemical: Spermicides and pills � Mechanical: Condom, diaphragm, intrauterine device (IUD) � Behavioral: Abstinence, temperature-ovulation-cervical mucus (Billing’s method), or coitus interruptus � Sterilization: Vasectomy, tubal ligation, or hysterectomy • Discuss signs and symptoms of perimenopausal and menopausal Clients who are informed and active participants in their own changes with the woman: hot flashes, perspiration, and/or chilly health decisions, in collaboration with the health care provider sensations; numbness or tingling of skin; insomnia or restlessness; who can provide a screening of hormone levels, can relieve some of interrupted sleep; feelings of irritability, anxiety, or apprehension; the symptoms of menopause. feeling depressed or unhappy; sensations of dizziness or swimming in the head; feeling of weariness of mind and body associated with desire for rest; joint or muscle pain; headaches; quickening or acceleration of heartbeat; and sensation of “crawly skin” (like insects creeping over skin).54–56 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Ask the client about previous learning experiences in general Helps determine aspects of the client’s cognitive appraisal that and about those related to the current area of concern; e.g., has could impact learning. the client learned that he or she is a poor learner, that he or she does not have the intellectual ability to learn the type of information that is currently required, or that the smallest mistake in the activity to be learned could be fatal. • Monitor the client’s current level of anxiety. If level of anxiety Severe anxiety and impaired cognitive functioning can decrease the will inhibit learning, assist the client with anxiety reduction. client’s ability to attend to the environment in a manner that Refer to Anxiety (Chap. 8) for detailed interventions. facilitates learning. • Determine what the client thinks is most important in the The client’s cognitive appraisal can impact his or her willingness current situation. to attend to the information. This is especially true of adult learners. • Assist the client in meeting those needs that represent lower-level Promotes attention to learning. Reduces anxiety. needs on Maslow’s hierarchy so attention can be focused on the area of learning to be addressed; e.g., if the client is concerned that children are not being cared for while he or she is hospitalized, he or she may not be able to focus on learning. List the needs to be met here. • Sit with the client for [number] minutes 2 times each day to Facilitates client change and understanding by addressing the discuss the following (each discussion point can be added as client’s perceptions of need. When information is presented when appropriate to the client’s situation): the client is ready in a way that is meaningful for the client, it has � Have the client describe those issues that are most important greater impact.57,58 for them to address. � Provide all information in a format that is meaningful to the client. This includes careful selection of language and of the information provided. � Provide successive information based on client’s response to previous information presented. • Provide positive verbal reinforcement for the client’s efforts to Positive reinforcement increases behavior. learn. (Note here those statements that are reinforcing for this client.) • Establish learning goals with the client that ensure success. Success provides positive reinforcement and promotes continued (Note those goals here.) learning efforts. • Establish time to include significant others in the learning A change in one part of the system affects the whole system. If the experiences. During this interaction, address the concerns of intervention is developed with the input of significant others, then these support systems. (Note schedule here and those to be it has meaning to this support system.57,58 included.) • Include the client in group learning experiences, e.g., Provides the client with opportunity to learn from others and to medication groups. discuss new coping behaviors in a safe environment. Copyright © 2002 F.A. Davis Company 414 COGNITIVE-PERCEPTUAL PATTERN Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Determine current knowledge base by interviewing the patient Provides a stepping-stone to pieces of information that may be and have the patient state current knowledge regarding condition. incorrect or lacking. • Ensure that adaptive equipment, if needed, is functioning and Enhances communication process. used. • Encourage the patient to set the pace of the teaching sessions.59 Assists in keeping sessions focused on the patient’s ability to acquire new information. • Monitor for fatigue. Fatigue interferes with concentration and thus decreases learning. • Present small pieces of information in each session. Avoids overwhelming the patient. Promotes learning. • Use examples that can be related to the individual’s life and Adds realism to information, and makes transferring of information lifestyle. easier. • Determine whether there is increased anxiety during teaching Anxiety decreases concentration and ability to learn. sessions; e.g., watch body language. If so, use relaxation techniques prior to session. • Use audiovisual aids that are appropriate for the individual in Promotes visual and sensory input according to the individual’s regard to print size, colors, volume, and tone pitch. needs. • Use repetition with positive feedback for correct responses. Reinforces learning and allows evaluation of learning. Home Health NOTE: Many of the interactions between clients, families, and the nurse during the course of home health care are related to health education. Proper assessment by the nurse of the potential for or ac- tual knowledge deficit is imperative. The nurse should use techniques based on learning theory to de- sign teaching interventions that will be appropriate to the situation at hand. These techniques include, but are not limited to, using teaching materials that match the readiness of the participant, repeating the material using several senses, reinforcing the learner’s progress, using a positive and enthusiastic approach, and decreasing barriers to learning, for example, language, pain, or physical illness. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family measures to reduce knowledge Conditions that support learning will decrease deficit. Provides the deficit by seeking the following information and learning client and family with necessary information. conditions: � Information regarding disease process � Rationale for treatment interventions � Techniques for improving learning situation (motivation, teaching materials that match cognitive level of participants, reduction of discomfort, e.g., control of pain and use of familiar surroundings) � Enhancement of self-care capabilities � Written materials to supplement oral teaching, i.e., written materials that are appropriate to cognitive level and to self-care management � Addressing client and family questions • Coordinate the teaching activities of other health care Coordination reduces duplication and enhances planning. Provides professionals who may be involved. Reinforce the teaching of an opportunity for health care professionals to clarify any ROM by the physical therapist, for example. conflicting information before sharing it with the client. • Involve the client and family in planning, implementing, and Involvement improves motivation and improves the outcome. promoting reduction in knowledge deficit: � Family conference � Mutual goal setting � Communication � Family members responsible for specific tasks or information • Consult with or refer to assistive resources as indicated. Use of the network of existing community services provides for effective utilization of resources. Copyright © 2002 F.A. Davis Company KNOWLEDGE, DEFICIENT (SPECIFY) 415 Knowledge, Deficient (Specify) FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate with 100% accuracy the designated skill? Yes No Record data, e.g., can Reassess using initial assessment factors. self-administer insulin with 100% accuracy; has return-demonstrated 6 times. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can self-administer insulin accurately 50% of time; common Did evaluation show another errors are [list here]. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 416 COGNITIVE-PERCEPTUAL PATTERN Memory, Impaired RELATED CLINICAL CONCERNS DEFINITION 1. Hypoxia 2. Anemia Inability to remember or recall bits of information or behavioral 3. Congestive heart failure skills.* 4. Alzheimer’s disease 5. Cerebral vascular accident NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ 6. Dementia COGNITION; CLASS 4—COGNITION NIC: DOMAIN 3—BEHAVIORAL; CLASS P— COGNITIVE THERAPY HAVE YOU SELECTED THE CORRECT DIAGNOSIS? NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS J—NEUROCOGNITIVE This diagnosis is very similar to other diagnoses in this pattern; for example, DEFINING CHARACTERISTICS2 Confusion and Disturbed Thought Process. However, this diagnosis relates specifically 1. Inability to recall factual information to memory problems. 2. Inability to recall recent or past events 3. Inability to learn or retain new skills or information 4. Inability to determine whether a behavior was performed 5. Observed or reported experiences of forgetting EXPECTED OUTCOME 6. Inability to perform a previously learned skill 7. Forgets to perform a behavior at a scheduled time Will exhibit no memory deficit problem by [date]. RELATED FACTORS2 TARGET DATES 1. Fluid and electrolyte imbalance For

some patients, this may be a permanent problem, so dates 2. Neurologic disturbances would be stated in terms of weeks and months. For other patients, 3. Excessive environmental disturbances it would be appropriate to check for progress within 3 days. 4. Anemia 5. Acute or chronic hypoxia 6. Decreased cardiac output NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Identify self and the patient by name at each interaction. Memory loss necessitates frequent orientation to person, time, and environment. • Support and reinforce the patient’s efforts to remember bits of Reinforcing the patient’s efforts at remembering can decrease information or behavioral skills. However, do not place anxiety levels and perhaps help with further recovery. Placing unrealistic expectations on the patient in this area. unrealistic expectations on the patient can increase anxiety, frustration, and feelings of helplessness. • Observe for improvement or deterioration in memory based on Memory impairment due to some reversible physiologic problem the suspected or confirmed underlying medical diagnosis. should improve as the condition becomes resolved. Memory impairment due to irreversible physiologic-physical problems generally will not improve and will likely deteriorate over time. • Teach the family about the patient’s condition and how to Assists the family in understanding underlying cause(s) for memory respond to the patient’s loss of memory. impairment. Increases the family’s sense of competency in relating to the patient during periods of memory loss. *Impaired memory may be attributed to pathophysiologic or situational causes that are either temporary or permanent. Copyright © 2002 F.A. Davis Company MEMORY, IMPAIRED 417 Child Health Same as Adult Health within developmental capacity for infant or child and safety-mindedness in all aspects. ACTIONS/INTERVENTIONS RATIONALES • Determine all who may need to be involved to best support the Ambiguous unknowns present frustration for all involved, so it is infant or child in situations where actual known level of best to establish most complete team to manage care to foster involvement may not be clear. holistic approach. • Offer 30 min each shift and as needed for the parents to Reduces anxiety and offers insight into parental concerns. ventilate concerns. • Offer appropriate advocacy on behalf of the infant or child when Child advocacy will best protect the child’s interests when the the parents are unable to offer this component. parents cannot. Women’s Health Same as Adult Health except for magnesium sulfate therapy specific to pregnancy-induced hypertension. For midlife women, the actions and interventions are the same as those given for perimenopausal and menopausal life periods in Deficient Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the client’s level of anxiety, and refer to Anxiety Anxiety can increase the client’s confusion and disorganization. (Chap. 8) for detailed interventions related to this diagnosis. • Speak to the client in brief, clear sentences. Too much information can increase the client’s confusion and disorganization, increasing memory problems. • Interact with the client for [number] minutes every 30 min. Time of interaction should be guided by the client’s attention span. Begin with 5-min interactions and gradually increase the length of interactions. • Be consistent in all interactions with the client. Facilitates the development of a trusting relationship, and meets the client’s safety needs. • Initially, place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to the client’s sense of disorganization and confusion, increasing memory problems. • Orient the client to the environment, and assign someone to Promotes the client’s safety needs while promoting the development provide one-to-one interaction while the client orients to unit. of a trusting relationship. • Do not argue with the client about inaccurate memory of Communicates acceptance of the client and promotes self-esteem. situations, e.g., the client insisting they have not eaten when he or she has just finished a meal. Inform the client in a matter-of-fact manner that this is not your experience of the situation. • Provide orientation information to the client as needed. Specify Facilitates maintenance of self-esteem and memory. here what information this client needs, e.g., name on room, calendar, clock, written daily schedule, or information provided in written form in a notebook. • Utilize reflection of the last statement made by the client in Facilitates memory within conversation. conversations. • Establish a daily schedule for the client, and provide a written Decreases anxiety and promotes consistency. copy to him or her. Note the client’s specific schedule here. • Spend [number] minutes [number] times a day reviewing with Associating information from various senses enhances memory by the client concerns about memory and developing memory providing meaningful links. Written material provides prompts. techniques. These could include visual imagery, mnemonic devices, memory games, association techniques, making lists, rehearsing information, or keeping a journal about activities. • Practice memory techniques with the client [number] minutes Practice improves performance and integrates behavior into the 2 times a day. Note specific techniques to be practiced. client’s coping strategies. • Spend [number] minutes following an activity discussing the Opportunities to use memory enhance memory. activity to provide the client with an opportunity to practice remembering. • Provide positive verbal reinforcement to the client for Positive feedback encourages behavior. accomplishing task progress. (continued) Copyright © 2002 F.A. Davis Company 418 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Sit with the client each morning and develop a list of the day’s Provides practice with memory techniques. activities. Review this list each evening. • Schedule the client for groups that provide opportunities to Provides opportunities for the client to practice using memory, utilize memory. These could be current event groups, which enhances memory. reminiscence groups, or life review groups. Note the client’s group(s) schedule here, with the assistance needed from staff to get the client to the group. • Spend [number] minutes each week discussing the client’s Support system reactions impact the client. coping strategies with support system. Note here person responsible and time for this discussion. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Introduce self with each client contact. Promotes comfort for the client to identify caregiver. • Use the client’s preferred name in course of conversations. Provides orienting cue to the client’s identity. • Request photographs and names of significant others from the Provides information about the client and point of reference while family or caregiver. providing care. • Maintain sameness of environment. Decreases need to cope with change on a frequent basis. • Document any appliances client requires (prostheses, eyeglasses, Provides a record of needed equipment that the client may not be hearing aids, cane, or walker). able to recall. • Ensure permanent identification of all appliances required by Assists in keeping equipment available to the client, and eliminates the client. potential of using incorrect assistive devices. • Maintain consistent routine of care. Provides sense of the familiar. • Avoid arguments over forgetful behavior. Promotes client self-esteem, and decreases potential for escalating anxiety related to the memory loss. • Omit statements or questions that emphasize memory loss such Promotes client self-esteem, and decreases potential for escalating as “Don’t you remember eating breakfast?” or “Do you know anxiety related to the memory loss. who came to see you this morning?” • In congregate social or living situations, introduce clients prior Fosters social skills and interactions. to group activities. • Monitor solid and liquid intake on a daily basis. Memory loss may prevent the client from obtaining adequate nutrition or fluid intake. • Document responses to medications, and note any changes in Some medications may have side effects that in the older client memory associated with medications. promote amnesia. This problem can occur especially with long-acting benzodiazepines and hypnotics. • Administer mental status examination on a semi-annual basis Monitors memory function and may assist in identifying changing unless the client is receiving medication to enhance memory. strengths. Increased frequency recommended if the client is taking memory-improving medication. • Monitor for changes in activities of daily living (ADLs) ability If memory loss is progressive, ADL skills will decrease over time and for performance of ADLs without prompting. and increased assistance will be needed. • Use distraction techniques if the memory-impaired client Distraction can allow time for the client to forget cause of agitation. becomes increasingly agitated or aggressive in the care setting. • Educate the caregiver to recognize signs of personal stress when Decreases potential for caregiver burnout. caring for the client with impaired memory. • Provide the caregiver information on respite services in Decreases potential for caregiver burnout. community. • Monitor the patient for changes in elimination patterns. The memory-impaired client may not be able to report changes in bowel or bladder function. Home Health NOTE: If this is an acute development, immediate referral is required. ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in lifestyle adjustments that may be Home-based care requires involvement of the family. Impaired necessary: memory can disrupt family schedules and role relationships. � Provide safe environment. Adjustments in family activities and roles may be required. (continued) Copyright © 2002 F.A. Davis Company MEMORY, IMPAIRED 419 (continued) ACTIONS/INTERVENTIONS RATIONALES � Provide frequent orientation to person, place, and time. � Structure teaching methods and interventions to the person’s ability. � Explain to the family the changes from their usual roles required in caring for the patient. • Assist the family to set criteria to help them determine when Provides the family with background knowledge to seek additional intervention is required, e.g., explain how to appropriate assistance as need arises. recognize change in baseline behavior. • Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the person with impaired memory. Use of readily available resources is cost-effective. • Teach the client and family memory involvement tasks, such as Structured memory tasks can increase the client’s functional ability. reminiscence and memory practice exercises. • Teach the client and family compensation strategies, e.g., daily Compensation strategies can increase the client’s functional ability. planner or checklists. Copyright © 2002 F.A. Davis Company 420 COGNITIVE-PERCEPTUAL PATTERN Memory, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient exhibiting any signs or symptoms of memory deficit? Yes No Reassess using initial assessment factors. Record data, e.g., has had no episodes of memory impairment for 3 days. Oriented  3. Record RESOLVED. Delete nursing diagnosis, expected outcome, target Is diagnosis validated? date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., continues to experience episodes of memory problems. Not oriented to time Yes No and place. Record CONTINUE and change target date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company PAIN, ACUTE AND CHRONIC 421 Pain, Acute and Chronic 4. Changes in sleep pattern 5. Fatigue DEFINITIONS2 6. Fear of reinjury 7. Reduced interaction with people Acute Pain Unpleasant sensory and emotional experience arising 8. Altered ability to continue previous activities from actual or potential tissue damage or described in terms of such 9. Sympathetic-mediated responses (temperature, cold, changes damage (International Association for the Study of Pain). Sudden of body position, or hypersentivity) or slow onset of any intensity from mild to severe with an antici- 10. Anorexia pated or predictable end and a duration of less than 6 months. Chronic Pain Unpleasant sensory and emotional experience aris- RELATED FACTORS2 ing from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain). Sud- A. Acute Pain den or slow onset of any intensity from mild to severe, constant or 1. Injury agents (biologic, chemical, physical, psychological) recurring, without anticipated or predictable end and a duration of B. Chronic Pain longer than 6 months. 1. Chronic physical or psychosocial disability RELATED CLINICAL CONCERNS NANDA TAXONOMY: DOMAIN 12—COMFORT; CLASS 1—PHYSICAL COMFORT 1. Any surgical diagnosis NIC: DOMAIN 1—PHYSIOLOGICAL: BASIC; 2. Any condition labeled chronic, for example, rheumatoid arthritis CLASS E—PHYSICAL COMFORT PROMOTION 3. Any traumatic injury 4. Any infection NOC: DOMAIN V—PERCEIVED HEALTH; 5. Anxiety or stress CLASS V—SYMPTOM STATUS 6. Fatigue DEFINING CHARACTERISTICS2 HAVE YOU SELECTED A. Acute Pain THE CORRECT DIAGNOSIS? 1. Verbal or coded report 2. Observed evidence There are no other nursing diagnoses that are 3. Antalgic positioning to avoid pain easily confused with this diagnosis.

Many of 4. Protective gestures the other nursing diagnoses will serve as 5. Guarding behavior companion diagnoses and may have pain as 6. Facial mask a contributing factor to that diagnosis; for 7. Sleep disturbance (eyes lack luster, beaten look, fixed or example, an individual with chronic pain scattered movement, or grimace) may be exhausted from trying to deal with 8. Self-focus the pain and have a companion diagnosis of 9. Narrowed focus (altered time perception, impaired thought Fatigue or may be using alcohol or street process, or reduced interaction with people and environment) drugs in an attempt to ease the pain and 10. Distraction behavior (pacing, seeking out other people would have the companion diagnosis of and/or activities, or repetitive activities) Ineffective Individual Coping. 11. Autonomic responses (diaphoresis; changes in blood pres- sure, respiration, pulse; pupillary dilation) 12. Autonomic change in muscle tone (may span from listless to rigid) EXPECTED OUTCOME 13. Expressive behavior (restlessness, moaning, crying, vigi- lance, irritability, or sighing) Will require no more than one medication for pain per 24 hours by 14. Changes in appetite and eating [date]. B. Chronic Pain 1. Weight changes TARGET DATES 2. Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self- For the majority of health disruptions, pain will begin to resolve focusing, restlessness, depression within 72 hours after the patient has sought health care assistance. 3. Atrophy of involved muscle group Thus, the suggested target date is 3 days after the date of diagnosis. Copyright © 2002 F.A. Davis Company 422 COGNITIVE-PERCEPTUAL PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for pain at least every 2 h on [odd/even] hour. Have the Pain is subjective in nature, and only the patient can fully patient rank pain on a scale of 0–10 at each incidence of pain. describe it. Record all pain ratings in a consistent format. Review and have the patient review activity engaged in prior to each pain episode and document. Request the patient to share thoughts and feelings prior to onset of painful episode. • Teach the patient to report pain as soon as it starts. Allow the Initiates a preventive approach before the pain gets too severe. patient to talk about pain experience in as much detail as desired. • Administer pain medication as ordered. Monitor and record Response to pain and pain medication is unique to each patient. amount of pain relief within 30 min after administration. Have patient re-rank pain (0–10). If pain not relieved, collaborate with physician regarding change in medication. • Consider round-the-clock dosing for patients with consistent Avoids a roller coaster effect in pain relief. pain. • Give massage immediately following administration of each pain Assists in muscle relaxation and improves action of pain medication medication and after each turning. by stimulating peripheral nerve fibers to close the transmission gate. • Turn at least every 2 h on [odd/even] hour. Maintain anatomic Helps stimulate circulation. Alignment helps prevent pain from alignment with pillows or other padded support. malposition and enhances comfort. • Provide calm, quiet environment. Limit activity for at least 2 h Promotes action and effect of medication by providing decreased following pain medication administration. stimuli. • Monitor vital signs at least every 4 h while awake at [times]. Detects early changes that might indicate pain. • Monitor sleep-rest pattern. Promote rest periods during day and Fatigue may contribute to an increased pain response, or pain can at least 8 h sleep each night (see nursing actions for Disturbed contribute to interrupted sleep. Sleep Pattern, Chap. 6). • Offer 2–3 oz of wine before each meal and at bedtime. Promotes relaxation and assists in decreasing pain response. • Promote activity and exercise to extent possible (i.e., so long as Promotes release of natural endorphins and stimulates circulation. it does not result in pain). Provide ROM exercises at least every Prevents complications of immobility secondary to limitation of 4 h while awake at [times]. movement because of pain. • Apply heat or cold (on 2 h, off 2 h). Select heat, cold, dry, or Causes vasoconstriction or vasodilation, either of which, depending moist, according to what the patient states provides the best on the individual patient’s response, will assist in decreasing pain relief. swelling, promote healing, and inhibit the transmission of the pain impulse. • Check bowel elimination at least once per shift. Immobility caused by pain may decrease the parasympathetic stimulation to the bowel. Many analgesics have constipation as a side effect. • When opioids are ordered, initiate mild laxatives concurrently. Prevents constipation, a common side effect of opioids. • Encourage fluid intake every 2 h while awake on [odd/even] Maintains hydration. The patient may limit intake because seeking hour. Encourage up to 3000 mL per day. fluids stimulates pain. • Provide oral hygiene every 4 h while awake at [times]. Basic comfort measure. • Allow time for the patient to discuss fears and anxieties related Just as pain is unique to the individual, so is the pain control to pain by scheduling at least 15 min once per shift to visit with intervention. Discussions with the patient provide collaboration the patient on one-to-one basis. Provide accurate information to and increase the patient’s compliance. Decreases feeling of the patient regarding: powerlessness, and initiates basic teaching regarding control of � Pain threshold pain. � Pain tolerance � Addiction � Medication effectiveness and ineffectiveness � Expressing pain • Apply mentholated or aspirin ointment to affected area every Provides topical relief for pain. Dulls peripheral nerve endings that 4 h while awake at [times] and when needed. carry pain impulse. • Use noninvasive pain relief techniques as appropriate: Provides diversion from pain. Decreases anxiety and muscle tension. � Biofeedback Increases comfort and empowers the patient. � Progressive relaxation � Guided imagery � Rhythmic breathing (continued) Copyright © 2002 F.A. Davis Company PAIN, ACUTE AND CHRONIC 423 (continued) ACTIONS/INTERVENTIONS RATIONALES � Distraction � Contralateral stimulation � Stress reduction techniques � Self-hypnosis • Collaborate with physician regarding use of transcutaneous Collaboration promotes the best approach to pain management. electrical nerve stimulation (TENS). • Teach the patient and significant others: Knowledge assists the patient in feeling like an active participant on � Cause of pain the health team. Decreases sense of powerlessness. Promotes � Self-administration of pain medication effective pain management. � Common and expected side effects of analgesics � The low rate of addiction when narcotics are used for pain � The importance of maintaining round-the-clock dosing for continuous pain and preventive dosing for expected pain � Avoiding and minimizing pain � Splinting � Gradual increase in activities � Use of alternative noninvasive techniques (see previous nursing action) � Combining techniques, e.g., medication with relaxation technique � To try various pain relief measures and to alternate pain relief measures � To express anger, frustration, and grief with pain management and change in lifestyle � To be more active in his or her own pain management program and to note successes and minimize failure � Value of adequate rest and maintaining weight within normal range • Refer the patient to or collaborate with other health Collaboration promotes the best long-range plan for management professionals. of pain. Additional Information Keep current on comparative doses of analgesics, true effect of so-called potentiators, and noninvasive means of pain relief. Do not worry about a patient’s becoming addicted. With the average length of stay of 3 to 5 days, it is doubtful addiction could occur. Current research in this area shows an extremely low rate of addiction due to medication administration in a health care setting. The same research indicates that we undermedicate, rather than overmedicate, for pain. Undermedication is particularly true in the case of infants, children, and older adults. See the Department of Health and Human Services Guidelines60 for a discussion of this research as well as further information on pain control. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributory factors to pain at least every 8 h or as Provides the essential database for planning and modification of required: planning. � Physical injury or surgical incision � Stressors � Fears � Knowledge deficit � Anxieties � Fatigue � Description of exact nature of pain whether per the McGill or Elkind pain assessment tools � Vital signs � Response to medication � Meaning of pain to the child and family • Provide appropriate support in management of pain for the Validation and support of the patient and family will serve to show patient and significant others by: value and respect for the individual’s health need. Maintains basic � Validation of the pain standards of care. Ventilation reduces anxiety, and parental � Maintaining self-control to extent feasible involvement enhances coping skills. (continued) Copyright © 2002 F.A. Davis Company 424 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Providing education to deal with specifics applicable; assisting the patient and family to talk about the pain experience by allowing at least 30 min per shift for such ventilation at [times] � Allowing the parents to be present and participate in comforting of the patient; assisting the child and parents to develop a plan of care that addresses individual needs and is likely to result in a better coping pattern (particularly for chronic pain) � Appropriate diversional activities for age and developmental level � Attention to controlling external stimuli such as noise and light � Use of relaxation techniques appropriate for the child’s capacity � Appropriate follow-up of pain tolerance and response to medication as ordered • Encourage pain medication route to be oral if there is no IV. • If IV route is utilized, monitor for respiratory and blood pressure depression every 10 min  6 at [times]. • Monitor intake and output for decrease as a result of hypomotility or spasm. • Give appropriate emotional support during painful procedures or experiences: � Give explanations in the child’s level of openness and honesty. � Use puppets to demonstrate procedure. � Explain to the parents that even if the child cries excessively, their presence is encouraged. � Comfort child before, during, and after procedure. � Reward the child for positive behavior according to developmental need, e.g., stars on a chart. � Discuss and encourage the parents and child to share feelings about the painful experience. • Collaborate with or refer the patient to appropriate health care team members. • Teach the patient and family ways to follow up at home or school with needed pain regimen: � Appropriate timing of medication � Appropriate administration of medication � Not to substitute acetaminophen for aspirin in arthritis • Monitor for stomach alterations or other complications, especially respiratory depression, secondary to administration of pain medication. • Develop daily plans for pain management to determine those that might be suited for the patient to use on a regular basis. • Identify need to have several alternate plans to deal with pain. NOTE: Chronic pain is going to recur; therefore, there is a need for long-term follow-up. This follow- up is especially critical because chronic pain places the patient at risk for developmental delays. Women’s Health Gynecologic Pain NOTE: A significant amount of the pain experienced by women is associated with the pelvic area and the reproductive organs. Determining the origin of the pain is one of the most difficult tasks facing nurses dealing with the gynecologic patient. An organic explanation for pain is never found in ap- proximately 25 percent of women. Because of the close association with the reproductive organs, gy- necologic pain can be extremely frightening, can connote social stigma, affect the perception of the feminine role, cause anger and guilt, and totally dominate the woman’s existence. “Pain is culturally more acceptable in certain parts of the body and may elicit more sympathy than pain in other sites.”61 ACTIONS/INTERVENTIONS RATIONALES • Identify factors in the patient’s lifestyle that could be contributing Provides the database to adequately assess pain and determine the to pain. underlying cause. (continued) Copyright © 2002 F.A. Davis Company PAIN, ACUTE AND CHRONIC 425 (continued) ACTIONS/INTERVENTIONS RATIONALES • Record accurate menstrual cycle and obstetric, gynecologic, and sexual history, being certain to note problems, previous pregnancies, descriptions of previous labors, previous infections or gynecologic problems, and any infections as a result of sexual activities. • Assist the client to describe her perception

of pain as it relates to her. • Include dysmenorrhea pain pattern, being certain to determine whether the pain occurs before, during, or after menstruation. • Monitor disturbance of the client’s daily routine as a result of pain. Have the patient describe the location of the pain, e.g., lower abdomen, legs, breast, or back. • Have the patient describe any edema, especially “bloating” at specific times during the month. • Have the patient describe the onset and character of the pain, e.g., mild or severe cramping. • Ascertain whether pain is associated with nausea, vomiting, or diarrhea. • Identify any precipitating factors associated with pain, e.g., This information can assist in pinpointing source of pain and emotional upsets, exercise, or medication. devising a plan of care. • Assist the patient in identifying various method of pain relief, Individualizes pain control, and provides options for the patient. including exercise (pelvic rock), biofeedback, relaxation, and medication (analgesics and antiprostaglandins). Women’s Health Labor Pain and Nursing ACTIONS/INTERVENTIONS RATIONALES LABOR • Encourage the patient to describe her perception of labor pain Providing information about the laboring process helps the patient related to her previous laboring experiences.62 cope with the pain of labor. • Provide factual information about the laboring process. • Refer the patient to childbirth preparation group, e.g., Lamaze groups. • Describe methods of coping with labor pain, e.g., relaxation, imaging, breathing, medication, hydrotherapy, or ambulation. • Provide support during labor. • Encourage involvement of significant others as support during labor process. POST PARTUM • Encourage the patient to describe her perception of pain associated with the postpartum period. • Provide information for pain relief, e.g., Kegel exercises, sitz baths, or medications. • Explain etiology of “afterbirth pains” to involution of uterus. Knowing the source of pain increases the patient’s sense of control. • Explain relationship of breastfeeding to involution and uterine contractions. • Assist the patient in putting on supportive bra. • Encourage early, frequent breastfeedings to enhance let-down reflex. • Support the patient and provide information on correct Knowledge of how to lessen discomfort during breastfeeding breastfeeding techniques, such as changing positions from one contributes to successful or effective breastfeeding. feeding to next to distribute sucking pressure and prevent sore nipples. • Check the baby’s position on breast; be certain areola is in mouth and not just the nipple. • Provide warm, moist heat for relief of engorged breasts. Demonstrates to the patient various pain relief methods. • Provide analgesics for discomfort of engorged breasts. (continued) Copyright © 2002 F.A. Davis Company 426 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Pump after the infant nurses until breast is emptied. • Encourage the patient to nurse on least sore side first to encourage let-down reflex. • Apply ice to nipple just before nursing to decrease pain. Psychiatric Health NOTE: Pain in the mental health client should be carefully assessed for physiologic causes. The follow- ing interventions are for pain associated with psychological factors or chronic pain. For chronic pain, they are used in conjunction with physiologic interventions. ACTIONS/INTERVENTIONS RATIONALES • Monitor nurse’s response to the client’s perception of pain. If the The nurse’s response to the client can be communicated and have nurse has difficulty understanding or coping with the client’s an effect on the client’s level of anxiety, which can then affect the expression of pain, he or she should discuss his or her feelings pain response. with a colleague in an attempt to resolve the concerns. • Note any recurring patterns in the pain experience, such as time Initiates the client’s awareness of this pattern, and allows the nurse of day, recent social interactions, or physical activity. If a pattern to assess the client’s perception of this observation. is present, begin a discussion of this observation with the client. • Determine effects pain has had on the client’s life, including role Assesses meaning of pain to the client’s amount of anxiety associated responsibilities, financial impact, cognitive and emotional with the pain and possible benefits of pain in the client’s life. functioning, and family interactions. • Review the client’s beliefs and attitudes about the role pain is If pain is assuming an important role, then it might be difficult for assuming in the client’s life. If pain is very important to the the client to “give up” all of the pain, and this should be considered client’s definition of self, assure the client that you are not in all further interventions.49,50 requiring him or her to give up the pain by indicating that you are only interested in that pain that causes undue discomfort or by indicating that this client’s pain is special and that it would be difficult, if not impossible, for the health care team to get rid of it. • Spend brief, goal-directed time with the client when he or she is focusing conversation on pain or pain-related activities. • Schedule time with the client when he or she is not complaining Provides positive feedback to the client about an aspect of himself about pain. List this schedule here. Focus on special activities in or herself that is not pain related. which the client is involved or follow-up on a non-pain-related conversation the client seemed to enjoy. • Find at least one non-pain-related activity the client enjoys that Reinforcement encourages a positive behavior and improves can be the source of positive interaction between the client and self-esteem. others, and encourage client participation in this activity with positive reinforcement (list client-specific positive reinforcers here along with the activity). • Discuss with the client alternatives for meeting personal need currently being met by pain. You may need to refer the client to another, more specialized care provider if this is a problem of long standing or if the client demonstrates difficulty in discussing these concerns. Refer to the self-esteem diagnoses (Chap. 8) for specific interventions related to perceptions of self. • Develop with the client a plan to alter those factors that intensify The social milieu can change the basic quality of the pain the pain experience. For example, if the pain increases at 4 p.m. experience. each day and the client associates this with his boss’s daily visit at 5 p.m., then the plan might include limiting the visits from the boss or having another person present when the boss visits. List specific interventions here. • Develop with the client plan for learning relaxation techniques, These techniques decrease anxiety. and have the client practice technique 30 min 2 times a day at [times]. Remain with the client during practice session to provide verbal cues and encouragement as necessary. These techniques can include: � Meditation � Progressive deep muscle relaxation (continued) Copyright © 2002 F.A. Davis Company PAIN, ACUTE AND CHRONIC 427 (continued) ACTIONS/INTERVENTIONS RATIONALES � Visualization techniques that require the client to visualize scenes that enhance the relaxation response (such as being on the beach or having the sun warm the body) � Biofeedback � Prayer � Autogenic training • Monitor interaction of analgesic with other medications the These medications may potentiate one another. client is receiving, especially antianxiety, antipsychotic, and hypnotic drugs. • Review the client’s history for indication of illicit drug use and The client may have developed a cross-tolerance for these drugs. the effects this may have on the client’s tolerance to analgesics. • If the client is to be withdrawn from the analgesic, discuss the Promotes perception of control, and decreases anxiety. alternative coping methods and how they will assist the client with the process. Assure the client that support will be provided during this process. Help the client identify those situations that will be most difficult, and schedule one-to-one time with the client during these times. • If the client demonstrates altered mood, refer to Ineffective Individual Coping (Chap. 11) for interventions. • Consult with occupational therapy to assist the client in Decreases conscious awareness of pain, thus decreasing the pain developing diversional activities. Note time for these activities experience. here as well as a list of special equipment that may be necessary for the activity. • Involve the client in group activities by sitting with him or her Alters the client’s perception of the pain. during a group activity, such as a game, or assign the client a responsibility for preparing one part of a unit meal. Begin with activities that require little concentration, and then gradually increase the task complexity. • Consult with physician for possible referral for use of hypnosis in pain management. • Sit with the client and the family during at least 2 visits to assess family interactions with the client and the role pain plays in family interaction. • Discuss with the client the role of distraction in pain management, Provides other pain relief options for the client. and develop a list of those activities the client finds distracting and enjoyable. These could include listening to music, watching television or special movies, or physical activity. Develop with the client a plan for including these activities in the pain management program, and list that plan here. • Discuss with the client the role that exercise can play in pain Exercise encourages release of natural endorphins. management, and develop an exercise program with the client. This should begin at or below the client’s capabilities and could include a 15-min walk twice a day or 10 min on a stationary bicycle. Note the plan here, with the type of activity, length of time, and time of day it is to be implemented. • Provide positive reinforcement to the client for implementing Positive reinforcement encourages repeating the behavior and the exercise program by spending time with the client during the enhances self-esteem. exercise, providing verbal feedback, and allowing the client the rewards that have been developed. These rewards are developed with the client. • Monitor family and support system understanding of the pain Assists the family in normalizing and in moving away from a and perceptions of the client. If they demonstrate the attitude pain-focused identity. that the client is closely perceived with the pain, then develop a plan to include them in the experiences described here. List that plan here. Consider referral to a clinical specialist in mental health nursing or a family therapist to assist the family in developing non-pain-related interaction patterns. • Provide ongoing feedback to the client or support system progress. • Refer to outpatient support systems, and assist with making Long-term support enhances the likelihood of effective home arrangements for the client to contact these before discharge. management. Copyright © 2002 F.A. Davis Company 428 COGNITIVE-PERCEPTUAL PATTERN Gerontic Health ACTIONS/INTERVENTIONS RATIONALES ACUTE PAIN • Medicate every 4–6 h rather than on an as needed (PRN) basis Enhances pain control, and thus promotes early mobility, which for the first 48–72 h, especially postoperatively.63 decreases the potential for postoperative complications. • Encourage physician to prescribe morphine versus meperidine Meperidine is more likely to cause confusion and psychotic if a narcotic analgesic is required. behavior when given to the older adult.64 • Investigate the patient’s beliefs regarding pain. Does he or she May be a barrier to seeking pain relief. consider pain a punishment for prior misdeeds? Does he or she think that having to take pain medication signals severe illness or a potential for dying?65 • Encourage the patient to report pain, especially if medication Patient may not realize that medication won’t be given on a order is PRN. scheduled basis. • Avoid presenting self in a hurried manner. Older adults are less likely to report pain if caregiver is rushed.65 CHRONIC PAIN • Explore with the patient how he or she has managed chronic Assists in determining what measures were of significant or of little pain in the past. help. • Determine use of distraction in helping the patient cope with Music, humor, and relaxation techniques can provide temporary chronic pain.63 respite from discomfort. • Monitor skin status when thermal interventions are used, such Changes in sensation may result in thermal injury if not closely as ice or heat packs. monitored. • In the presence of chronic pain, depression may also exist. Chronic pain is exhausting physically and mentally. Screen for depression. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family measures to promote comfort: Involvement of the client and family promotes comfort and � Proper

positioning decreases self-reported pain and analgesic use.63 � Appropriate use of medications, e.g., narcotics as ordered if pain is severe, nonnarcotic analgesics, anti-inflammatories � Knowledge regarding source of pain or of disease process � Self-management of pain and of care as much as is appropriate � Relaxation techniques � Therapeutic touch � Massage (if not contraindicated) � Meaningful activities � Distraction � Breathing techniques � Heat or cold treatments (if not contraindicated) � Regular activity and exercise � Planning and goal setting � Biofeedback � Yoga or tai chi � Imagery or hypnosis � Group or family therapy • Teach the client and family factors that decrease tolerance to Reducing these factors can increase the tolerance to pain.64 pain and methods for decreasing these factors: � Lack of knowledge regarding disease process or pain control methods � Lack of support from significant others regarding the severity of the pain � Fear of addiction or fear of loss of control � Fatigue � Boredom � Improper positioning • Involve the client and family in planning, implementing, and Involvement improves motivation and improves outcome. promoting reduction in pain: (continued) Copyright © 2002 F.A. Davis Company PAIN, ACUTE AND CHRONIC 429 (continued) ACTIONS/INTERVENTIONS RATIONALES � Family conference � Mutual goal setting � Communication � Support for the caregiver • Assist the client and family in lifestyle adjustments that may be Lifestyle changes require changes in behavior. required: � Occupational changes � Family role alterations � Comfort measures for chronic pain � Financial situation � Responses to pain (mood, concentration, or ability to complete activities of daily living) � Coping with disability or dependency � Mechanism for altering need for assistance � Providing appropriate balance of dependence and independence � Stress management � Time management � Obtaining and using assistive equipment, e.g., for arthritis � Regular, rather than as-needed, schedule of pain medication • Teach the client and family purposes, side effects, and proper Provides necessary information for safe self-care. administration techniques of medications. • Consult with or refer to appropriate assistive resources as Use of the existing community services network provides effective indicated. utilization of resources. Copyright © 2002 F.A. Davis Company 430 COGNITIVE-PERCEPTUAL PATTERN Pain, Acute and Chronic FLOWCHART EVALUATION: EXPECTED OUTCOME Review prn medication record. Has the patient required more than one analgesic in past 24 h? Yes No Reassess using initial assessment factors. Record data, e.g., medication administration record (MAR) review shows patient has required no analgesic for past 48 h; no complaints of pain documented in nurses’ notes; patient states pain is no longer a problem. Record RESOLVED. Delete nursing Is diagnosis validated? diagnosis, expected outcome, target date, and nursing actions. Did evaluation show a new Yes No problem had developed? Record data, e.g., MAR review shows required five analgesics in past 24 h. Record CONTINUE and change target Yes No date. Modify nursing actions as necessary. Finished Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, Start new evaluation process. target date, and nursing actions. Delete invalidated diagnosis. Copyright © 2002 F.A. Davis Company SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 431 Sensory Perception, Disturbed (Specify: 7. Electrolyte imbalance 8. Biochemical imbalance Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) RELATED CLINICAL CONCERNS DEFINITION 1. Any neurologic diagnosis 2. Glaucoma or cataracts Change in the amount or patterning of incoming stimuli accompa- 3. Intensive care unit patient nied by a diminished, exaggerated, distorted, or impaired response 4. Psychosis to such stimuli.2 5. Substance abuse 6. Toxemia NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ COGNITION; CLASS 3—SENSATION/PERCEPTION NIC: DOMAIN 3—BEHAVIORAL; CLASS Q— HAVE YOU SELECTED COMMUNICATION ENHANCEMENT THE CORRECT DIAGNOSIS? NOC: DOMAIN II—PHYSIOLOGIC HEALTH; CLASS Y—SENSORY FUNCTION Disturbed Thought Process Disturbed Thought Process refers to a patient’s cognitive abilities, whereas Disturbed DEFINING CHARACTERISTICS2 Sensory Perception relates to just the sensory input-output. 1. Poor concentration Self-Care Deficit Certainly sensory 2. Auditory distractions perception problems could result in self-care 3. Change in usual response to stimuli deficits; however, one diagnosis refers to 4. Restlessness ability to care for the self, whereas the other 5. Reported or measured change in sensory acuity focuses on response to sensory input. 6. Irritability 7. Disoriented in time, in place, or with people 8. Change in problem-solving abilities 9. Change in behavior pattern EXPECTED OUTCOME 10. Altered communication patterns 11. Hallucinations Will identify and initiate at least two adaptive ways to compensate 12. Visual distortions for [specific sensory deficit] by [date]. RELATED FACTORS2 TARGET DATES 1. Altered sensory perception Assisting the patient in dealing with an uncompensated sensory 2. Excessive environmental stimuli deficit is a long-term process. Also, the patient may never accept the 3. Psychological stress deficit but can be helped to adapt to the deficit. Therefore, an ap- 4. Altered sensory reception, transmissions, and/or integration propriate target date would be no sooner than 5 to 7 days from the 5. Insufficient environmental stimuli date of diagnosis. 6. Biochemical imbalances for sensory distortion (e.g., illusions or hallucinations) NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Provide the patient with appropriate prosthesis if the deficit has Provides immediate assistance with sensory deficit to decrease been previously diagnosed and prosthesis provided. deficit. • Maintain prosthesis to ensure optimal functioning. Prosthesis that does not fit or function well leads to nonuse. • Provide calm, nonthreatening environment. Reinforces reality. • Orient to room. • Check safety factors frequently: Basic safety measures. � Siderails � Uncluttered room � Lighting: Dim at night, increased during day, and nonglare � Environment arranged to assist in compensating for specific deficit (continued) Copyright © 2002 F.A. Davis Company 432 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Place bedside table and over-the-bed table in same position each Maintains consistency of environment, which facilitates the time and within easy reach. Ascertain which items the patient patient’s comfort and decreases anxiety. wants on these tables and where the items are to be placed. Place items in same place each time. • Have significant others bring familiar items from home. Enhances physical and psychological comfort. • Promote consistency in care, e.g., same nurse, as near same Decreases unessential stimuli. Inspires trust. Reinforces the routine as possible. patient’s own routine. • Follow the patient’s own routine as much as possible, e.g., bath, Promotes comfort and empowers the patient. bedtime, meals, and grooming. Pace activities to the patient’s preference. • Provide reality orientation as necessary: Reinforces reality. � Keep clock and calendar in room. � Touch the patient frequently. � Check orientation to person, time, and place at least once per shift. � Listen carefully. • Monitor, at least once per shift: Basic monitoring for signs and symptoms of sensory overload or � Intake and output sensory deficit. � Vital signs � Circulatory status � Neurologic status � Sleep-rest amounts � Mental status • Encourage activity and exercise to extent possible, and Provides stimulation and prevents complications from immobility. interspace with rest periods. Do ROM at least every 4 h while awake at [times]. • Collaborate with occupational therapist regarding appropriate Provides stimuli. diversionary activity. AUDITORY DEFICIT • Clean ear with wet washcloth over finger. Assists in removal of earwax without damaging inner ear structure. • If ear drops are ordered, warm to body temperature before Warm ear drops assist in removal of earwax and are less likely to instilling into the ear. cause vertigo problems. Increases comfort. • Speak in low tones when interacting with the patient. Allows for alteration in hearing high-frequency sounds. High-frequency tones are lost first. • Allow the patient extended time to respond to verbal messages. Allows for understanding and interpretation of message. • Decrease background noise as much as possible when talking Avoids confusion, and increases the patient’s ability to localize with the patient. sounds. • Do not shout when talking with the client. Shouting only accentuates vowel sounds while decreasing consonant sounds. • Use visual cues as much as possible to enhance verbal messages. Improves communication. • Provide message board to use with the patient. • Replace batteries in hearing aids as necessary. A common problem in hearing deficits. • Clean earwax from ear mold of hearing aid as necessary. Improves functioning of hearing aid. • Stand where the patient can watch your lips when you are speaking to him or her. • Make lips visible to the patient by clipping moustaches away Provides added cues to what is being said. from lips (males) or wearing lipstick that highlights lips (females). • Teach the patient and family proper care of ears, e.g., use of ear Protects the eardrum from trauma. plugs when in an environment with loud noises, protecting the ear from water while swimming, blowing the nose with mouth and both nostrils open. • Teach the patient to turn better ear toward speaker. Note here Improves communication. the patient’s better ear so staff can stand on that side when speaking to the patient. • Teach the patient and family proper maintenance of hearing aid. Promotes proper functioning of hearing aid. VISUAL DEFICIT • Provide the patient with his or her eyeglasses or contact lenses Facilitates the patient’s use of equipment, and assists in preventing during waking hours. Note here where they are to be kept when damage or loss of equipment. the patient is not using them, and place them in that place when the patient removes them. (continued) Copyright © 2002 F.A. Davis Company SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 433 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide written information in large-print or audio recorded format. • Provide telephone dials and other equipment necessary that have large numbers on nonglare surfaces. List here special equipment that is necessary for this patient and when the patient may need it so it can be provided at appropriate times. • Identify the patient’s room with large numbers or the patient’s name in large print. • Provide large-screen television and pictures with large, colorful Larger images are easier for the patient to interpret. images. • Place the patient in social or group situations so he or she is not Glare from window will decrease visual acuity. looking directly into an open window. • Provide nonglare work surfaces. • Identify stairs and doorframes with contrasting tape or paint. Increases visual acuity. Basic safety measure. • Verbally address the patient when entering the patient’s Makes the patient aware of presence. proximity, and approach the patient from the front. • Do not alter the patient’s physical environment without telling Promotes consistency in environment, which improves safety. him or her of the changes. • Address the patient by name. Clearly identifies who you are talking to. • Ask the patient about special environmental adaptations he or Promotes familiarity of environment while in hospital. she prefers or uses (list those here). • Provide the patient with audio books and large-print periodicals. Provides diversionary activity. • Enter the patient’s environment every hour on the Frequent contact provides assurance that the patient is a matter of [hour/half-hour]. concern to the nursing staff. • Teach the patient and family proper maintenance of eyeglasses Ensures proper functioning and prevents scratching of lenses. and other prosthesis. • Teach the patient and family methods to improve environmental safety. • Assist the patient with ADLs as necessary. List the activities that Allows the patient to be as independent as possible. require assistance here, along with the type of assistance that is needed, e.g., assisting the patient to eat to extent necessary (feed totally or cut up food and open packages). TOUCH AND KINESTHESIA DEFICIT • Remove sharp objects from the patient’s environment. Basic safety measure. • Protect the patient from exposure to excessive heat and cold by: Basic safety measures to prevent accidental burns. � Checking temperature of heat and cold packs carefully before application � Teaching the patient to check with a thermometer the temperature of bath and other water to be placed on the skin � Checking temperature of bathwater for the patient while he or she is on the nursing unit � Teaching the patient to wear protective clothing whenever he or she goes outdoors in the winter � Teaching the patient not to use heating pads or hot-water bottles • Have the patient and family lower the setting on the hot-water heater in the home to 124F. • Instruct the patient not to smoke unless someone is with him

or her. • Have the patient change position every 2 h on [even/odd] hour. Promotes circulation, and relieves pressure on bony prominences. • Monitor condition of skin every 4 h at [times]. Note any Guards against skin breakdown. alteration in integrity. Teach the patient to visually inspect skin on a daily basis. • Have the patient wear well-fitting shoes when walking. Prevents blisters and infection. • Trim toenails and fingernails for the patient. Maintain these at a safe length. • Assist the patient in determining whether clothing is fitting properly without abrading the skin. • Perform foot care on a daily basis to include: � Bathing feet in warm water � Applying moisturizing lotion (continued) Copyright © 2002 F.A. Davis Company 434 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Trimming nails as needed � Checking skin for abrasions or reddened areas • Note time for foot care here. This process should be taught to the patient, and the patient should be assuming primary responsibility for this care before discharge. This should be done with nursing supervision. • Provide the patient with assistance with movement in the environment until he or she is able to make the necessary adaptations to alterations in sensations. • Consult with physical therapist regarding teaching the patient Demonstrates and promotes safe care of extremities for the patient. appropriate adaptations for safe and effective movement. • Assist the patient with care of affected body parts. Prevents unilateral neglect, and provides cues for the patient. • Assist the patient with ADLs (note type and amount of assistance Promotes self-care through demonstrating care to the patient. needed here). • Refer the patient to occupational therapy for assisting with learning new self-care behavior. OLFACTORY DEFICIT • Assess for extent of neurologic dysfunction on admission. Determines what intervention can be planned. • Determine effect the smell deficit has on the patient’s appetite, Assists to compensate for loss of smell. and work with dietitian to make meals visually appealing. • Provide for appropriate follow-up appointments before dismissal. Providing specific appointments lessens the confusion about the specifics of appointments and increases the likelihood of subsequent follow-through. Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine how the parent and child perceive the deficit Appropriate attention to both subjective as well as objective data is addressed by setting aside adequate time (30 min) each shift required to best plan care. for discussion and listening. • Stress the importance of follow-up evaluation for any suspected Preventing or minimizing secondary and tertiary deficits is sensory deficits of infants and young children. enhanced by appropriate attention to sensory perception follow-up. • Allow for extra anticipatory safety needs according to sensory Sensory deficits and developmental capacity increase the risk of deficit and the child’s developmental capacity. accidents. • Initiate plans for home dismissal at least 4 days before discharge Adequate practice time in a nonjudgmental situation allows positive to allow time for confidence in performance of necessary tasks feedback and corrective action. Lessens anxiety and performance according to deficit. pressures. Increases confidence in giving care at home. • Provide attention to family coping as it may relate to the deficit: A child with sensory perception problems and the interventions � Assessment of usual dynamics necessary to deal with these problems place strain on the family. � Identification of impact on the parents and siblings Promoting coping will lessen strain for the family while increasing � Presence of mental deficits the likelihood that the child’s needs will be met. � Values regarding the deficit � Support systems • Review for appropriate immunization, especially rubella, In the event of early deficits, the likelihood exists for the need to mumps, and measles. modify the schedule of immunization. This is too often overlooked and will then place the infant or child at unnecessary risk for infectious diseases. • In presence of ear infections, exercise caution regarding use of Treatment for chronic infections with antibiotics by several ototoxic medications such as gentamicin. practitioners must be carried out with precaution for potential side effects. • Correlate medical history for potential risk factors such as Contributory factors to the pattern of health must be pursued with chronic middle ear infections, upper respiratory infections, or openness to all possible causes. allergies. • Provide appropriate sensory stimulation for age, beginning Appropriate sensory stimulation will favor gradual progress in slowly so as not to overload child. development. • Deal with other contributory factors such as nutrition, illness. Related factors must be considered in total health of the infant or child with altered sensory-perceptual pattern. (continued) Copyright © 2002 F.A. Davis Company SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 435 (continued) ACTIONS/INTERVENTIONS RATIONALES • Include the parents in plans for rehabilitation whenever Inclusion of the parents provides an opportunity for learning possible by: essential skills and enhances security of the infant or child. All � Using basic plan for care efforts contribute to empowerment and potential growth of the � Adapting intervention as required for the child family unit. � Supporting them in their role � Pointing out opportune times for interaction � Informing them of appropriate safety precautions for the child’s age and situation � Encouraging gentle handling and comforting of the infant • Provide continuity in staffing for nursing care of the child and Continuity provides trust and opportunities for reinforcement of family. learning. • In instances of a handicapped child, provide appropriate Appropriate introduction of new skills or reinforcement of existent attention to developing sequencing to best actualize potential patterns will favor progress. offered. • Especially note, on follow-up, the home environment for The home to which the infant or child will go may require nurturing aspects and support systems. reasonable adaptation to foster appropriate resources. Women’s Health ACTIONS/INTERVENTIONS RATIONALES VISION • Monitor the patient for signs of pregnancy-induced Knowledge of signs of visual disturbances associated with PIH can hypertension (PIH). assist the patient in seeking early treatment. • Monitor for signs and symptoms of preeclampsia, e.g., headaches, visual changes such as blurred vision, increased edema of face, oliguria, hyperreflexia, nausea or vomiting, and epigastric pain. • Teach the patient the importance of reporting these signs and symptoms, because they can be precursors to eclampsia. SMELL • Be aware of the patient’s tendency during early pregnancy to experience morning sickness, i.e., nausea and vomiting. • In collaboration with dietitian: � Obtain dietary history. � Assist the patient in planning diet that will provide adequate nutrition for her and her fetus’s needs. • Teach methods for coping with gastric upset, nausea, and Knowledge can assist the patient in planning actions to decrease vomiting: incidences of nausea and vomiting and assist in preventing � Eating bland, low-fat foods dehydration and possibly hospitalization. � Increasing carbohydrate intake � Eating small, frequent meals � Having dry crackers or toast before getting out of bed � Taking vitamins and iron with snack before going to bed � Supplementing diet with high-protein liquids, e.g., soups or eggnog TOUCH DURING PREGNANCY • Be aware of the expectant mother’s sensitivity to extraneous Assists the mother to know that her feelings are normal. touching: � Shyness � Protectiveness of unborn child � Uterine sensitivity during pregnancy and particularly during labor MATERNAL TOUCH • Encourage visual and tactile contact between the mother and Provides time for beginning attachment process between the infant as soon as possible. mother and infant. • Provide conducive atmosphere for continual mother-infant contact. (continued) Copyright © 2002 F.A. Davis Company 436 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Delay newborn eye treatment for 1 h, so that the baby can see the mother’s face. KINESTHESIA • Be aware of the expectant mother’s increased vulnerability Reassures mothers that this is a temporary state. related to physical size of body in third trimester: � Protectiveness of unborn child � Heavy movement � Possible slowed reflexes � Tires easily • Assist in and out of furniture that is too low and difficult to get out of. • Encourage correct body mechanics when lying down or sitting up. • Encourage to wear seat belt when traveling in automobile Provides for safety measures for the mother and fetus. (shoulder belt best). Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the client’s neurologic status as indicated by current Client safety is of primary importance. Early recognition and condition and history of deficit, e.g., if deficit is recent, intervention can prevent serious alterations. assessment would be conducted on a schedule that could range from every 15 min to every 8 h. Note frequency and times of checks here. If checks are to be very frequent, then it might be useful to keep a record of these checks on a flow sheet. • If deficit is determined to result from a psychological rather Client safety is of primary importance. than a physiologic dysfunction, refer to Ineffective Individual Coping, Disturbed Body Image, Anxiety, and Chronic Low or Situational Low Self-Esteem for detailed nursing actions. NOTE: A comprehensive physical examination and other diagnostic evaluations should be completed before this determination is made. Each of these deficits can be symptoms of severe physiologic or neurologic dysfunction and should be approached with this understanding, especially in a mental health environment where the clients may be assigned without careful assessment. This is a great risk for the client who has a history of mental health problems. • If deficit is related to a physiologic dysfunction, attend to needs Provides positive reinforcement for adaptive coping behaviors. resulting from the identified sensory deficit in a matter-of-fact manner, providing basic care and having the client do the majority of the care. • If deficit is related to a psychological dysfunction, spend 15 min Promotes the client’s sense of control, and increases self-esteem. every hour with the client in an activity that is not related to the sensory deficit. If the client begins to focus on the deficit, terminate the interaction. • Spend 1 h twice a day discussing with the client the effects the deficit will have on his or her life and developing alternative coping behavior. Note times for conversations here. If the family is involved in the client’s care, they should be included on a planned number of these interactions. • Refer to appropriate mental health professional if the client is going to require long-term assistance in adapting to the deficit or if current emotional adaptation becomes complicated. • Discuss with the client and support system the necessary Promotes the client’s sense of control. alterations that may be necessary in the home environment to facilitate daily living activities. (continued) Copyright © 2002 F.A. Davis Company SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 437 (continued) ACTIONS/INTERVENTIONS RATIONALES AUDITORY OR VISUAL ALTERATIONS66–69 • Observe for signs of hallucinations (intent listening for no Interrupts patterns of hallucinations. apparent reason, talking to someone when no one is present, muttering to self, stopping in mid-sentence, or unusual posturing). When these symptoms are noted, engage the client in here-and-now, reality-oriented conversation or involve the client in here-and-now activity. • Initiate touch only after warning the client that you are going to The client may perceive touch as a threat and respond in an touch him or her. aggressive manner. • Communicate acceptance to the client to encourage the sharing Provides information on the content of the hallucination so early of the content of the hallucination. intervention can be initiated when content suggests harm to the client or others. • If hallucinations place the client at risk for self-harm or harm to Client and staff safety are of primary importance. others, place the client on one-to-one observation or in seclusion. • If the client is placed in seclusion, interact with the client at Provides reality orientation, and assists the client in controlling the least every 15 min. hallucinations. • Have the client tell staff when hallucinations are present or Early intervention promotes the client’s sense of safety and control. when they are interfering with the client’s ability to interact with others. • Maintain environment in a manner that does not enhance High levels of environmental stimuli can increase the client’s hallucinations, e.g., television programs that validate the disorganization and confusion. client’s hallucinations, abstract art on the walls, wallpaper with abstract designs, or designs that enhance imagination. • Teach the client to control hallucinations by: Promotes the client’s sense of control, and enhances