Professional Documents
Culture Documents
Davis Company
Clinical
Applications of
Nursing Diagnosis
Copyright 2002 F.A. Davis Company
Clinical
Applications of
Nursing Diagnosis
Adult, Child, Womens,
Psychiatric, Gerontic and
Home Health Considerations
Fourth Edition
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
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Copyright 2002 F.A. Davis Company
Preface
The North American Nursing Diagnosis Association (NANDA) has been identifying, classifying,
and testing diagnostic nomenclature since the early 1970s. In our opinion, use of nursing diag-
nosis helps dene the essence of nursing and give direction to care that is uniquely nursing care.
If nurses (in all instances we are referring to registered nurses) enter the medical diagnosis of, for
example, acute appendicitis as the patients problem, they have met defeat before they have begun.
A nurse cannot intervene for this medical diagnosis; intervention requires a medical practitioner
who can perform an appendectomy. However, if the nurse enters the nursing diagnosis Pain, then
a number of nursing interventions come to mind.
Several books incorporate nursing diagnosis as a part of planning care. However, these books
generally focus outcome and nursing interventions on the related factors; that is, nursing inter-
ventions deal with resolving, to the extent possible, the causative and contributing factors that re-
sult in the nursing diagnosis. We have chosen to focus nursing intervention on the nursing diag-
nosis. To focus on the nursing diagnosis promotes the use of concepts in nursing rather than
concentrating on a multitude of specics. For example, there are common nursing measures that
can be used to relieve pain regardless of the etiologic pain factor involved. Likewise, the outcomes
focus on the nursing diagnosis. The main outcome nurses want to achieve when working with the
nursing diagnosis Pain is control of the patients response to pain to the extent possible. Again, the
outcome allows the use of a conceptual approach rather than a multitude-of-specics approach.
To clarify further, consider again the medical diagnosis of appendicitis. The physicians rst con-
cern is not related to whether the appendicitis is caused by a fecalith, intestinal helminths, or
Escherichia coli run amok. The physician focuses rst on intervening for the appendicitis, which
usually results in an appendectomy. The physician will deal with etiologic factors following the
appendectomy, but the appendectomy is the rst level of intervention. Likewise, the nurse can deal
with the related factors through nursing actions, but the rst level of intervention is directed to re-
solving the patients problem as reected by the nursing diagnosis. With the decreasing length of
stay for the majority of patients entering a hospital, we may indeed do well to complete the rst
level of nursing actions.
Additionally, there is continuing debate among NANDA members as to whether the current
list of diagnoses that are accepted for testing are nursing diagnoses or a list of diagnostic categories
or concepts. We, therefore, have chosen to focus on concepts. Using a conceptual approach al-
lows focus on independent nursing functions and helps avoid focusing on medical intervention.
This book has been designed to serve as a guide to using NANDA-accepted nursing diagnoses as
the primary base for the planning of care. The expected outcomes, target dates, nursing actions,
and evaluation algorithms (owcharts) are not meant to serve as standardized plans of care but
rather as guides and references in promoting the visibility of nursings contribution to health care.
Marjory Gordons Functional Health Patterns are used as an organizing framework for the
book. The Functional Health Patterns allow categorizing of the nursing diagnoses into specic
groups, which, in our opinion, promotes a conceptual approach to assessment and formulation
of a nursing diagnosis.
Chapter 1 serves as the overview-introductory chapter and gives basic content related to the
process of planning care and information regarding the relationship between nursing process and
nursing models (theories). Titles for Chapters 2 through 12 are taken from the functional pat-
terns. Included in each of these chapters is a list of diagnoses within the pattern, a pattern de-
scription, pattern assessment, conceptual information, and developmental information related to
the pattern.
The pattern description gives a succinct summary of the patterns content and assists in explain-
ing how the diagnoses within the pattern are related. The list of diagnoses within the pattern is given
vii
Copyright 2002 F.A. Davis Company
viii PREFACE
to simplify location of the diagnoses. The pattern assessment serves to pinpoint information from the
initial assessment base and was specically written to direct the reader to the most likely diagnosis
within the pattern. Each assessment factor is designed to allow an answer of yes or no. If the pa-
tients answer or signs are indicative of a diagnosis within the pattern, the reader is directed to the
most likely diagnosis or diagnoses. The conceptual and developmental information is included to
provide a quick, ready reference to the physiologic, psychological, sociologic, and age-related fac-
tors that could cause modication of the nursing actions in order to make them more specic for
your patient. The conceptual and developmental information can be used to determine the rationale
for each nursing action.
Each nursing diagnosis within the pattern is then introduced with accompanying information
of denition, dening characteristics, and related factors. We have added a section titled Related
Clinical Concerns. This section serves to highlight the most common medical diagnoses or clus-
ter of diagnoses that could involve the individual nursing diagnosis.
Immediately after the related clinical concerns section is a section titled Have you selected the
correct diagnosis? This section was included as a validation check because we realize that sev-
eral of the diagnoses appear very closely related and that it can be difcult to distinguish between
them. This is, in part, related to the fact that the diagnoses have been accepted for testing, not as
statements of absolute, discrete diagnoses. Thus, having this section assists the reader in learning
how to pinpoint the differences between diagnoses and in feeling more comfortable in selecting
a diagnosis that most clearly reects a patients problem area that can be helped by nursing ac-
tions.
After the diagnosis validation section is an outcome. The expected outcome serves as the end
point against which progress can be measured. Different agencies may call the expected outcome
an objective, a patient goal, or an outcome standard. Readers may also choose to design their own
patient-specic expected outcome using the given expected outcome as a guideline.
Target dates are suggested following the expected outcome. The target dates do not indicate the
time or day the outcome must be fully achieved; instead, the target date signies the time or day
when evaluation should be completed in order to measure the patients progress toward achieve-
ment of the expected outcome. Target dates are given in reference to short-term care. For home
health, particularly, the target date would be in terms of weeks and months rather than days.
Nursing actions/interventions and rationales are the next information given. In most instances,
the adult health nursing actions serve as the generic nursing actions. Subsequent sets of nursing
actions (child health, womens health, psychiatric health, gerontic health, and home health) show
only the nursing actions that are different from the generic nursing actions. The different nursing
actions make each set specic for the target population, but must be used in conjunction with the
adult health nursing actions to be complete. Rationales have been included to assist the student
in learning the reason for particular nursing actions. Although some of the rationales are scien-
tic in nature, that is, supported by documented research, other rationales could be more ap-
propriately termed common sense or usual practice rationales. These rationales are reasons
nurses have cited for particular nursing actions and result from nursing experience, but research
has not been conducted to document these rationales. After the home health actions, evaluation
algorithms are shown that help judge the patients progress toward achieving the expected out-
come.
Evaluation of the patients care is based on the degree of progress the patient has made toward
achieving the expected outcome. For each stated outcome, there is an evaluation owchart (al-
gorithm). The owcharts provide minimum information, but demonstrate the decision-making
process that must be used.
In all instances, the authors have used the denitions, dening characteristics, and related fac-
tors that have been accepted by NANDA for testing. A grant was provided to NANDA by the F. A.
Davis Company for the use of these materials. All these materials may be ordered from NANDA
(1211 Locust Street, Philadelphia, PA 19107). Likewise, a fee was paid to Mosby for the use of
the domains and classes from McCloskey, JC, and Bulechek, GM (eds): Nursing Interventions Clas-
sication (NIC), edition 3 (Mosby, St. Louis, 2000) and Johnson, M, Maas, M, and Moorhead, S
(eds): Nursing Outcomes Classication, edition 2 (Mosby, St. Louis, 2000).
In some instances, additional information is included following a set of nursing actions. The
additional information includes material that either needs to be highlighted or does not logically
fall within the dened outline areas.
Throughout the nursing actions we have used the terms patient and client interchangeably. The
terms refer to the system of care and include the individual as well as the family and other social
support systems. The nursing actions are written very specically. This specicity aids in com-
munication between and among nurses and promotes consistency of care for the patient.
There has been a tremendous increase in the activity of NANDA. In 1998 alone, 16 new diag-
Copyright 2002 F.A. Davis Company
PREFACE ix
noses were accepted, 32 diagnoses were revised, and one diagnosis was deleted. The ofcial jour-
nal of NANDA became an international journal in 1999.
The fourth edition incorporates new and revised diagnoses from both the Thirteenth (1998)
and Fourteenth (2000) NANDA Conferences. The proposed NANDA Taxonomy 2 has been in-
serted to replace the old Taxonomy 1, Revised. The Nursing Interventions Classication (NIC)
system and the Nursing Outcomes Classication (NOC) system domains and classes have been
incorporated.
Other revisions have been made to be consistent with current NANDA thought and publica-
tions. One example is the deletion of major and minor dening characteristics and their assimi-
lation under one heading of Dening Characteristics.
We continue to appreciate the feedback we have received from various sources and urge you
to continue to assist us in this way. It is our sincerest wish that this book will continue to assist
nurses and nursing students in their day-to-day use of nursing diagnosis.
Helen C. Cox, RN, C, EdD, FAAN
Copyright 2002 F.A. Davis Company
Acknowledgments
Contents
CHAPTER 1
Introduction 1
Purpose, 1
Denition, 1
Assessment, 3
Diagnosis, 4
Planning, 5
Implementation, 6
Documentation, 7
Evaluation, 9
Nursing Models, 9
Patterns, 10
SUMMARY, 14
CHAPTER 2
Health PerceptionHealth Management Pattern 15
PATTERN DESCRIPTION, 15
PATTERN ASSESSMENT, 15
CONCEPTUAL INFORMATION, 16
DEVELOPMENTAL CONSIDERATIONS, 18
Ineffective, 61
xi
Copyright 2002 F.A. Davis Company
xii CONTENTS
Protection, Ineffective, 75
CHAPTER 3
Nutritional-Metabolic Pattern 86
PATTERN DESCRIPTION, 86
PATTERN ASSESSMENT, 86
CONCEPTUAL INFORMATION, 87
DEVELOPMENTAL CONSIDERATIONS, 89
Hyperthermia, 140
Hypothermia, 145
Nausea, 153
Nutrition, Imbalanced, More Than Body Requirements, Risk for and Actual, 166
CHAPTER 4
Diarrhea, 206
CHAPTER 5
CONTENTS xiii
Fatigue, 289
Gas Exchange, Impaired, 294
Infant Behavior, Disorganized, Risk for and Actual, and Readiness for
Wandering, 360
CHAPTER 6
Sleep-Rest Pattern 367
CHAPTER 7
Cognitive-Perceptual Pattern 381
xiv CONTENTS
CHAPTER 8
Anxiety, 456
Fear, 476
Hopelessness, 484
Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low, 508
CHAPTER 9
Alcoholism, 534
Parenting, Impaired, Risk for and Actual, and Parental Role Conict, 561
CHAPTER 10
CONTENTS xv
CHAPTER 11
CHAPTER 12
References, 721
Index, 733
CHAPTER 1
Introduction
(NANDA),* we believe this book makes it easier for you, the stu-
Why This Book? dent, to learn and use nursing diagnosis in planning care for your
When the rst edition of this book was written, all the authors were patients.
faculty members at the same school of nursing. We had become
frustrated with the books that were available for teaching nursing The Nursing Process
diagnosis to students and found that the students were also ex-
pressing some of the same frustration. PURPOSE
The students felt they needed to bring several books to the clin-
ical area because the books for nursing diagnosis had limited in- Gordon1 indicates that Lydia Hall was one of the rst nurses to use
formation on pathophysiology and psychosocial or developmental the term nursing process in the early 1950s. Since that time, the term
factors that had an impact on individualized care planning. The stu- nursing process has been used to describe the accepted method of de-
dents were also confused regarding the different denitions, den- livering nursing care. Iyer and coauthors2 state, The major purpose
ing characteristics, and related factors each of the authors used. The of the nursing process is to provide a framework within which the in-
students were having difculty writing individualized nursing ac- dividualized needs of the client, family, and community can be met.
tions for their patients because the various authors appeared to fo- It may be easier to think of a framework as a blueprint or an out-
cus on specics related to the etiology or signs and symptoms of the line that guides the planning of care for a patient. As Doenges and
nursing diagnosis rather than the concept represented by the nurs- Moorhouse write,3 The nursing process is central to nursing ac-
ing diagnosis that had been emphasized to our students. The au- tions in any setting because it is an efcient method of organizing
thors were also concerned about the number of books our students thought processes for clinical decision making and problem solv-
had to buy, because most books focused on just one clinical area, ing. Use of the nursing process framework is benecial for both the
such as adult health or pediatrics. Thus, as the students progressed patient and the nurse because it helps ensure that care is planned,
through the school, they had to buy different books for different individualized, and reviewed over the period of time that the nurse
clinical areas even though each of the books had the common and patient have a professional relationship. It must be emphasized
theme of the use of nursing diagnosis. Another concern we, as fac- that the nursing process requires the involvement of the patient
ulty, had was the lack of information in the various books regard- throughout all the phases. If the patient is not involved in all phases
ing the nal phase of the nursing processevaluation. This most then the plan of care is not individualized.
vital phase was briey mentioned, but very little guidance was
given in how to proceed through this phase. DEFINITION
The nal concern that led to the writing of the book was our
desire to focus on nursing actions and nursing care, not medical Alfaro4 denes nursing process as an organized, systematic method
care and medical diagnosis. We strongly believe and support the of giving individualized nursing care that focuses on identifying and
vital role of nurses in the provision of health care for our nation, treating unique responses of individuals or groups to actual or po-
and so we have focused in this book strictly on nursing. After all, tential alterations in health. This denition ts very nicely with the
statistics show that the largest number of health care providers are American Nurses Association (ANA) Social Policy Statement5: Nurs-
nurses and that the general public has a high respect for nurses. ing is the diagnosis and treatment of human responses to actual and
Therefore, let us work on developing our profession and its potential health problems. Alfaros denition is further supported by
contributions. the ANA Standards of Clinical Nursing Practice6 (Table 11), prac-
For these reasons, we have written this book particularly geared tice standards written by several boards of nursing,7 and the deni-
to student use. Specifically, we wrote this book to assist students tion of nursing that is written into the majority of nurse practice acts
to learn how to apply nursing diagnosis in the clinical area. By us-
ing the framework of the nursing process and the materials gen-
erated by the North American Nursing Diagnosis Association Throughout this book we use the terms patient and client interchange-
ably. In most instances these terms refer to the individual who is receiving
*Nursing diagnoses developed by and used with permission of North nursing care; however, a patient can also be a community, such as in the
American Nursing Diagnosis Association. NANDA Nursing Diagnoses: De- communityhome health nursing actions, or the patient can be a family,
nitions and Classication 20012002. NANDA, Philadelphia, 2001. such as for the nursing diagnosis Ineffective Family Coping, Compromised.
1
Copyright 2002 F.A. Davis Company
2 INTRODUCTION
4 INTRODUCTION
interview, she or he will get a rm idea of which body systems need processes. Nursing diagnoses provide the basis for selection of nurs-
detailed examination. An example is a cardiovascular examination, ing interventions to achieve outcomes for which the nurse is ac-
where the apical and radial pulses, blood pressure (BP), point of countable.
maximum intensity (PMI), heart sounds, and peripheral pulses are
examined. Much debate occurred during the Ninth Conference regarding this
The functional health pattern approach is based on Gordons Func- denition, and it is anticipated this debate will continue. The de-
tional Health Patterns typology and allows the collection of all types bate centers on a multitude of issues related to the denition, which
of data according to each pattern. This is the approach used by this are beyond the scope of this book. Readers are urged to consult the
book and leads to three levels of assessment. First is the overall ad- ofcial journal of NANDA, Nursing Diagnosis: The International Jour-
mission assessment, where each pattern is assessed through the col- nal of Nursing Language and Classication, to keep up to date on this
lection of objective and subjective data. This assessment indicates debate.
patterns that need further attention, which requires implementa- The denition of nursing diagnosis distinguishes nursing diag-
tion of the second level of pattern assessment. The second level of nosis from medical diagnosis. For example, nursing diagnosis is dif-
pattern assessment indicates which nursing diagnoses within the ferent from medical diagnosis in its focus. Kozier, Erb, and
pattern might be pertinent to this patient, which leads to the third Olivieri11 write that nursing diagnoses focus on patient response,
level of assessment, the dening characteristics for each individual whereas medical diagnoses focus on the disease process. As indi-
nursing diagnosis. Having a three-tiered assessment might seem cated by the denition of nursing diagnosis, nurses also identify po-
complicated, but each assessment is so closely related that comple- tential problems; physicians place primary emphasis on identifying
tion of the assessment is easy. A primary advantage in using this the current problem.
type of assessment is the validation it gives to the nurse that the re- Nursing diagnosis and medical diagnosis are similar in that the
sulting nursing diagnosis is the most correct diagnosis. Another same basic procedures are used to derive the diagnosis (i.e., phys-
benet to using this type of assessment is that grouping of data is ical assessment, interviewing, and observing). Likewise, according
already accomplished and does not have to be a separate step. to Kozier and associates,11 both types of diagnoses are designed for
essentially the same reasonplanning care for a patient.
A nursing diagnosis is based on the presence of dening charac-
Data Grouping teristics. According to NANDA,12 dening characteristics are clini-
cal criteria that represent the presence of the diagnostic category
Data grouping simply means organizing the information into sets or
(nursing diagnosis). For actual nursing diagnoses (the problem is
categories that will assist you in identifying the patients strengths
present), a majority of the dening characteristics must be present.
and problem areas. A variety of organizing frameworks is available,
For risk diagnoses (risk factors indicate the problem might de-
such as Maslows Hierarchy of Needs, Roys Adaptation Model, and
velop), the risk factors must be present.
Gordons Functional Health Patterns. Each of the nursing theorists
(e.g., Roy, Levine, and Orem) speaks to assessment within the
framework of their theories. Diagnostic Statements
Organizing the information allows you to identify the appropri-
ate functional health pattern and also allows you to spot any miss- According to the literature, complete nursing diagnostic statements
ing data. If you cannot identify the pertinent functional health pat- include, at a minimum, the human response and an indication of
tern, then you need to collect further data. The goal of data the factors contributing to the response. The following is a rationale
grouping is to arrive at a nursing diagnosis. for the two-part statement13:
Each nursing diagnosis, when correctly written, can accomplish
DIAGNOSIS two things. One, by identifying the unhealthy response, it tells you
what should change. . . . And two, by identifying the probable cause
Diagnosis means reaching a denite conclusion regarding the pa- of the unhealthy response, it tells you what to do to effect change.
tients strengths and problems. The problems are the primary focus
for planning care, and the strengths are used to assist you in im- Although there is no consensus on the phrase that should be used
plementing this care. In this book, we concentrate the diagnosis to link the response and etiologic factors, perusal of current litera-
phase of the nursing process on nursing diagnosis and use the di- ture indicates that the most commonly used phrases are related to,
agnoses accepted by NANDA for testing. secondary to, and due to.
The phrase related to is gaining the most acceptance because it
does not imply a direct cause-and-effect relationship. Kieffer14 be-
Nursing Diagnosis lieves using the phrases due to and secondary to may reect such a
The North American Nursing Diagnosis Association (NANDA), cause-and-effect relationship, which could be hard to prove. Thus,
formerly the National Conference Group for Classication of Nurs- a complete nursing diagnostic statement would read: Pain related
ing Diagnosis, has been meeting since 1973 to identify, develop, to surgical incision.
and classify nursing diagnoses. Setting forth a nursing diagnosis Gordon1 identies three structural components of a nursing di-
nomenclature articulates nursing language, thus promoting the agnostic statement: The problem (P), the etiology (E), and signs and
identication of nursings contribution to health, and facilitates symptoms (S). The problem describes the patients response or cur-
communication among nurses. In addition, the use of nursing di- rent state (the nursing diagnosis); the etiology describes the cause or
agnosis provides a clear distinction between nursing diagnosis and causes of the response (related to); and the symptoms delineate the
medical diagnosis and provides clear direction for the remaining as- dening characteristics or observable signs and symptoms demon-
pects of the planning of care. strated or described by the patient. The S component can be read-
NANDA accepted its rst working denition of nursing diagno- ily connected to the P and E statements through the use of the
sis in 199010: phrase as evidenced by. Using this format, a complete nursing diag-
nostic statement would read: Pain related to surgical incision as ev-
A nursing diagnosis is a clinical judgment about individual, family idenced by verbal comments and body posture.
or community responses to actual or potential health problems/life As discussed in the preface, we recommend starting with stating
Copyright 2002 F.A. Davis Company
6 INTRODUCTION
2. Serves to motivate both patients and nurses toward accomplish- any other health care practitioner, for example, deciding which
ing the expected outcome. noninvasive technique to use for pain control or deciding when to
3. Helps patient and nurse see accomplishments. teach the patient self-care measures. Collaborative actions are those
4. Alerts nurse when to evaluate care plan. activities that involve mutual decision making between two or more
health care practitioners, for example, a physician and nurse de-
Target dates can be realistically established by paying attention ciding which narcotic to use when meperidine is ineffective in con-
to the usual progress and prognosis connected with the patients trolling the patients pain, or a physical therapist and nurse decid-
medical and nursing diagnoses. Additional review of the data col- ing on the most benecial exercise program for a patient.
lected during the initial assessment helps indicate individual factors Implementing a physicians order and referral to a dietitian are
to be considered in establishing the date. For example, one of the other common examples of collaborative actions.
previous expected outcomes was stated as Accurately return- Written nursing actions guide both actual patient care and
demonstrates self-administration of insulin by 9/11. proper documentation, and they must therefore be detailed and ex-
The progress or prognosis according to the patients medical and act. Written nursing actions should be even more denite than
nursing diagnosis will not be highly signicant. The primary factor what is generally found in physician orders. For example, a physi-
will be whether diabetes mellitus is a new diagnosis for the patient cian writes the order, Increase ambulation as tolerated for a pa-
or is a recurring problem for a patient who has had diabetes melli- tient who has been immobile for 2 weeks. The nursing actions
tus for several years. should reect specied increments of ambulation as well as ongo-
For the newly diagnosed patient, we would probably want our ing assessment:
deadline day to be 5 to 7 days from the date of learning the diag-
nosis. For the recurring problem, we might establish the target date
to be 2 to 3 days from the date of diagnosis. The difference is, of
course, the patients knowledge base. 11/2 1.a. Prior to activity, assess BP, P, and R. After activity assess:
Now look at an example related to the progress issue. Mr. Kit is (1) BP, P, R; (2) presence/absence of vertigo; (3) circula-
a 19-year-old college student who was admitted early this morning tion; (4) presence/absence of pain.
with a medical diagnosis of acute appendicitis. He has just returned b. Assist to dangle on bedside for 15 minutes at least 4
from surgery following an appendectomy. One of the nursing di- times a day on 11/2.
c. If BP, P, or R change signicantly or vertigo is present
agnoses for Mr. Kit would, in all probability, be Pain. The expected
or circulation is impaired or pain is present, return to
outcome could be Will have decrease in number of requests for
supine position immediately. Elevate head of bed 30
analgesics by [date]. In reviewing the general progress of a young degrees for 1 hour; then 45 degrees for 1 hour; then 90
patient with this medical and nursing diagnosis, we know that gen- degrees for 1 hour. If tolerated with no untoward signs
erally analgesic requirements start decreasing within 48 to 72 or symptoms, initiate order 1b again.
hours. Therefore, we would want to establish our target date as 2 d. Assist up to chair at bedside for 30 minutes at least 4
to 3 days following the day of surgery. This would result in the ob- times a day on 11/3.
jective reading (assume date of surgery was 11/1): Will have de- e. Assist to ambulate to bathroom and back at least 4 times
crease in number of requests for analgesics by 11/3. a day on 11/4.
To further emphasize the target date, it is suggested that the date f. Supervise ambulation of one-half length of hall at least 4
be underlined, highlighted by using a different-colored pen, or cir- times a day on 11/5 and 11/6.
cled to make it stand out. Pinpointing the date in such a manner g. Supervise ambulation of length of hall at least 4 times a
emphasizes that evaluation of progress toward achievement of the day on 11/7.
expected outcome should be made on that date. In assigning the S. J. Smith, RN
dates, be sure not to schedule all the diagnoses and expected out-
comes for evaluation on the same date. Such scheduling would re-
quire a total revision of the plan of care, which could contribute to Nursing actions further differ from physician orders in that the
not keeping the plan of care current. Being able to revise single por- patients response is directly related to the implementation of
tions of the plan of care facilitates use and updating of the plan. Re- the action. It is rare to see a physician order that includes alter-
member that the target date does not mean the expected outcome natives if the first order has minimal, negative, or no effect on the
must be totally achieved by that time; instead, the target date sig- patient.
nies the evaluation date. A complete written nursing action incorporates at least the fol-
Once expected outcomes have been written, you are then ready lowing ve components according to Bolander15:
to focus on the next phaseimplementation. As previously indi-
cated, the title supported by this book for this section is Nursing 1. Date the action was initially written
Actions. 2. A specic action verb that tells what the nurse is going to do
(e.g., assist or supervise)
3. A prescribed activity (e.g., ambulation)
IMPLEMENTATION 4. Specic time units (e.g., for 15 minutes at least 4 times a day)
Implementation is the action phase of the nursing process; hence, we 5. Signature of the nurse who writes the initial action order (i.e.,
chose the term nursing actions. Two important steps are involved accepting legal and ethical accountability)
in implementation: The rst is determining the specic nursing ac- A nursing action should not be implemented unless all ve com-
tions that will assist the patient to progress toward the expected out- ponents are present. A nurse would not administer a medication if
come, and the second is documenting the care administered. the physician order read, Give Demerol; neither should a nurse
Nursing action is dened as nursing behavior that serves to help be expected to implement a nursing action that reads, Increase am-
the patient achieve the expected outcome. Nursing actions include bulation gradually.
both independent and collaborative activities. Independent actions Additional criteria that should be remembered to ensure com-
are those activities the nurse performs using his or her own discre- plete, quality nursing action, include:
tionary judgment and that require no validation or guidelines from
Copyright 2002 F.A. Davis Company
8 INTRODUCTION
10 INTRODUCTION
PATTERN DESCRIPTION
Health PerceptionHealth Management The patients awareness of personal health and well-being; health practices; understanding of
how health practices contribute to health status
Nutritional-Metabolic The patients description of food and uid 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 Patients overall activities of daily living, including recreational activity
Sleep-Rest Patients 24-h routine of rest, relaxation, and sleep
Cognitive-Perceptual Cognitive functional performance and sensory performance
Self-Perception and Self-Concept Patients self-assessment; attitudes, ability, worth; verbal and nonverbal communication
Role-Relationship Patients 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 difcult 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. 19951996. 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-
ecting the diagnostic labels. Table 14 lists the Human Response clear classication of diagnoses into the taxonomic patterns.
Patterns with accompanying brief denitions. 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 Gordons 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 15
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
12 INTRODUCTION
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 patients room were all kinds of dressings, u-
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 patients chart. The nurse then re-
eral and state legislated mandates, completion and use of nursing quested information from the patient who stated, I dont like to
care planning is going to increase in importance. Several insurance look at it, so I dont 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 nally
one of the rst 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 patients 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 dont do care plans because I dont 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 nations health.
pital, received her patient assignments and a brief report, and then
Copyright 2002 F.A. Davis Company
CHAPTER 2
Health Perception
a. Yes
Pattern Description b. No (Risk for Injury)
Nurses assist individuals, families, and communities who have lim- 4. Was the patient and family satised 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,
dentist, etc.) prescribed?
Pattern Assessment a. Yes (Effective Management of Therapeutic Regimen)
1. Review the patients 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, eld, move-
b. No (Risk for Infection; Ineffective Protection) ment, or sound) of the ow of energy surrounding the person?
3. Review sensory status (sight, hearing, touch, smell, and taste). Is a. Yes (Disturbed Energy Field)
the patients sensory status within normal limits? b. No
15
Copyright 2002 F.A. Davis Company
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 inuence 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. 21) 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 benecial.
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 patients 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) dene perceived benets 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 individuals level of readiness
A person who practices health management techniques, for exam- provides the energy to act, and the perception of benets 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 familys, 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- viduals 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.46
Various factors inuence a persons 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.
elds.1 Disturbance in these elds can produce symptoms. Another The Health Belief Model is disease specic. 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, fulllment, 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 eld 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 patients perception of the
An intact nervous system is also required, because it provides for situation, increasing the patients cues to action, and decreasing the
optimum functioning of sensory, motor, and cognitive activities. patients barriers to action, the nurse can enhance the possibility
An accurate cognitive-perceptual pattern and self-perceptionself- 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 individuals 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 inuences 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. 22)
health management. provides the framework for nursing research and practice. This
Cultural, societal, and familial values and beliefs also inuence model emphasizes the importance of cognitive-perceptual factors
the capacity to achieve positive health perception and health man- in behavior regulation. Cognitive-perceptual factorsfor example,
agement. Values and beliefs inuence what is identied as optimal understanding of the importance of health, understanding of the
health. Availability of appropriate health care resources in a com- denition of health, perceived self-competency, and perceived con-
munity impacts the health care delivery system and the ability of trol of healthare 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
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. 22. 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
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 inuence the health perceptionhealth 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 clinicians handbook, pre- from birth to approximately 24 months as described by Piagets sen-
ventive care timelines, ofce 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
patients strengths, not just the patients 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, humidier; (4) avoiding heating formula in
would: microwave; (5) using protection screens on heaters, replaces, and
electrical outlets; (6) using nonammable 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 brosis, vision
8. Maintain weight within normal range for age, sex, and height
impairment, and hearing deciency. 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 inuenzae 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 months1820
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 childs 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 rst 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 inuenzae 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
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 rened 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 scientic 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- nd 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 factors3032 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 decits.
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
Tuberculosis cases in the United States remain disproportionately CLASS 3ENERGY BALANCE
munity diseases.37
CLASS AACTIVITY AND EXERCISE MANAGEMENT
tory alterations may lead to an inability to smell smoke or gas CLASS AENERGY MAINTENANCE
fumes.37 The risk for injury and increases in self-care decits may
result from sensory, motor, or perceptual difculties. 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, owing)
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 reex, decreased gastrointesti- 5. Disruption of the eld (vacant, hold, spike, bulge)
nal motility, and urinary stasis can be problematic for the older
adult with a less efcient 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 efcient 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 deciency 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
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 eld. Alterations, variations, and/or asymmetry in the energy eld is
detected through assessment.42
Center self: Promotes accurate assessment.
Imagine self as open system with energy ow content in,
through, and out of the system.
Consciously quiet your mind; put aside or detach from
inward and outward distractions.
Be sensitive to any images that come to mind: words, symbols, There may be a loss of energy, disruption or blockage in the ow 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 eld.
Synthesize assessment data into an understandable format.
Redirect areas of accumulated energy, reestablish the energy Energy transfer or transformation can occur without direct physical
ow, and direct energy to depleted areas. Repattern or rebalance contact between two systems.42 Hands are focal points for the
patients energy eld. direction and modulation of energy.42
Do therapeutic touch for no longer than 10 min. Could disrupt the energy eld of the therapist.
Assess the patients 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
Assist the patient to consciously relax that tense area of the body. Rebalances energy ow through the body.45
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 elds may be related to numerous other altered
most conducive and therapeutic method for monitoring the patterns due to the infant or childs basic coping repertoire,
childs energy eld.46 especially altered thermoregulationaltered neurologic status.
(continued)
Copyright 2002 F.A. Davis Company
ACTIONS/INTERVENTIONS RATIONALES
Monitor energy eld with a focus on maintaining self-comforting Will enhance assessment of energy eld.
activities for the child. May begin with soft music and/or
soothing voice.47
Begin with gentle but rm pressure of hands on one another. Warms hands.
Assess energy eld from head to toe. Focus on determining sites Routine assessment.
where differences are present.
Attempt to redirect areas of lesser ow or greater ow within an Restores balance.
overall free-owing energy eld, allowing 121 in between The infant or child has a small energy eld.
nurses hands and the child.
Monitor the clients responses to therapeutic touch. Focus on Permits evaluation of success of therapy.
identifying stimulus response.
Teach the client (or family, depending on clients age) to note Promotes early intervention.
physical and mental cues that alter energy eld, especially
stressors.48,49
Offer age-appropriate relaxation techniques, e.g., imaginary Pays attention to developmental level.
oating 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 eld
balance.
As appropriate, assist family to develop ways to reduce sensitivity Provides long-term balance.
to external triggering cues.
Womens 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 clients past experience with
personal energy elds that do not reinforce delusional beliefs,
e.g., EEG and EKG measure electrical energy that ows from
the body; walking across the oor 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 clients cognitive map facilitates the development
their alterations. of interventions that facilitate client change.53
Select one of the following methods for altering energy elds All these techniques have been demonstrated to have effects on the
based on the assessment: bodys energy elds.44,45,5459 Application of these interventions by
Therapeutic touch the nurse is related to having appropriate training in the technique.
Foot or hand reexology 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
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 clients level of comfort.53,57
intervention:
Provide private, quiet environment.
Teach the client about the intervention.
Obtain the clients permission to utilize the intervention. Builds trust and promotes the clients sense of control.53
Provide appropriate music that increases the clients 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 clients Odors have impact on the limbic system and impact affect.
sense of well-being.
Focus own attention on the intent of the interaction. The nurses 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 elds 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 clients 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 ush on the face and neck
Clients 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 eld 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: elds.44,45,5458
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 prole (prescription and over-the-counter) to Medications may contribute to disturbed energy elds.
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 patients 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 adults needs.
(continued)
Copyright 2002 F.A. Davis Company
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 conict 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. benet from the reduced sympathetic response to stress. The
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 adults 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 identication assists in providing early intervention.
eld.
Teach the client and family techniques to prevent and/or treat Involvement improves motivation and improves the outcome.
disturbed energy eld. Self-care is enhanced.
Therapeutic touch
Foot or hand reexology
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 efcient use of resources.
community, such as:
Massage therapists
Reexologists
Stress reduction classes
Copyright 2002 F.A. Davis Company
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?
No Finished
Copyright 2002 F.A. Davis Company
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. Identication of the factors signicant
value clarication strategies. Factors may include: to the patient will provide the foundation for teaching positive
Stopping smoking50,6467 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 decits as he or she Increases the patients 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, modications, 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 signicant 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 benets and disadvantages Placing items in priority according to the patients 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 reects the daily activities needed to succeed in
health maintenance.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
NOTE: Developmental consideration should always guide the health maintenance planned for the
child patient. Also, identication 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 denitively reects specic
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, Identication 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.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to describe her perception and understanding Allows assessment of the patients basic level of knowledge so that
of essential information related to her individual lifestyle and a plan can begin at the patients 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
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
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 modied 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 specied tasks as appropriate
(e.g., cooking, cleaning, transportation, companionship, or
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
setting)
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.
No Finished
Copyright 2002 F.A. Davis Company
[date].
RELATED FACTORS41
To be developed. TARGET DATES
RELATED CLINICAL CONCERNS Changing a habit involves a signicant investment of time and en-
ergy regardless of whether the change involves starting a new habit
Because this diagnosis, as indicated by the denition, 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.
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., nancial 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 patients problem-solving abilities, and assist the Promotes shared decision making and enhances patients 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 condent in self-seeking health care behavior, e.g.,
teach assertiveness techniques to the patient and family.
(continued)
* Stable health status is dened 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the child and family for perceived value of health. Values are formulated in the rst 6 years of life and will serve as
Incorporate into any plan personal and family needs identied 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 conict. Until health-seeking behavior is identied
as a value, follow-up care will not be deemed to be benecial.
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 Childrens Services.
Womens 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
ACTIONS/INTERVENTIONS RATIONALES
Interaction 1: Have the client identify specic areas of concern. Promotes the clients perception of control.
List the identied concerns on the care plan. Also identify the
Interaction 2: List specic goals for each concern the client has Promotes the clients self-esteem when goals can be accomplished.
identied. 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 clients self-esteem and provides motivation for
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 denition of health, Awareness of denition of health, locus of control, perceived
perceived personal control, perceived self-efcacy, and efciency, and health status identies 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
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?
No Finished
Copyright 2002 F.A. Davis Company
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.7780
(continued)
Copyright 2002 F.A. Davis Company
ACTIONS/INTERVENTIONS RATIONALE
Maintain adequate nutrition and uid and electrolyte balance. Helps prevent disability that would predispose infection.
Provide a well-balanced diet with increased amounts of vitamin
C, sufcient iron, and 24002600 mL of uid 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 uid. identication 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 710 days, to kill causative organisms. Antibiotics may
destroy normal bowel ora, 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 efcient 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.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
During prenatal period, inform the mother about and how to Infections acquired during pregnancy can cause signicant
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 mothers
Getting correct amount of sleep ability to ght 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
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 38 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 u-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 rst 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 clients 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage clients to maintain immunization status, especially Older adults, with aging changes to the immune system, are at
annual u 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 u 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
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?
No Finished
Copyright 2002 F.A. Davis Company
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 patients status.
the clock. If the patient has been identied 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 patients 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 patients 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.
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
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 identication 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 infants 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 reux. 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 childs 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 t with crib frame.
Discourage sleeping in bed with the infant.
Avoid use of homemade paciers (use only those of
one-piece construction with loop handle).
Do not tie pacier around the infants neck.
Untie bibs, bonnets, or other garments with snug t 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,
swimming pool.
min at a time.
and development.
Womens 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 patients life
expectations.
Provide information on options available to the patient. This is Some states require that information about local womens 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 signicant 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
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Orient the client to person, place, and time on each interaction. Disorientation can increase the clients 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 clients current status so interventions can be adapted
consciousness is affected by drugs or alcohol. If level of appropriately. Prevents aspiration by facilitating drainage of uids
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 decits (e.g., use of pictures or colors to
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 difculty
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
specic interventions.)
Check the clients 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
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
rooms.
prone to wandering.
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 dene mutual goals.
Promote communication.
Assist family members with specic 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
pathways9092; remove unsafe or improperly stored chemicals,
weapons, cooking utensils, and appliances; use and store
safely toxic substances; obtain certication in rst aid and
CPR; properly store food; obtain knowledge of poisonous
plants; learn to swim; remove re hazards from environment;
design and practice an emergency plan for action if re 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 ames, 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
substances
as indicated
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 efcient 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
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,
Yes
target date, and nursing actions.
Delete invalidated diagnosis.
No Finished
Copyright 2002 F.A. Davis Company
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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
RISK FOR
Assess for signs and symptoms suggestive of latex allergy, Identication 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 individuals status assists in identication 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 Identication 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 identication alerts for records and
identication bands as the child is cared for to signify allergenic Proper identication 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
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 Identication 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 identication 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 signicant 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 childs latex allergy Valuing feelings and perceptions of the client and family fosters
status. open communication and provides cues for related nursing needs.
Womens 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 bida). spina bida 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
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 specic 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 identication 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
Yes No
No Finished
Copyright 2002 F.A. Davis Company
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 rst target date
To be developed. for 1 month after the patients discharge.
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 patients 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 patients 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; reafrms 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 patients
continue to encourage its use and the sharing of the plan with lifestyle.
the patients 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
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 clients and primary caregivers 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.
Womens 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 identied 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.101103
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 clients
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
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 specic 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 identied 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 systems perspective to assist in
developing interventions and further their acceptance of the
intervention.52
Develop with the members of the support system a plan to meet Increases support systems 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
identied 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 identication of problems. For the individual who is effectively managing care, the
nurse supports the current effective behavior.
Copyright 2002 F.A. Davis Company
Effective
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?
No Finished
Copyright 2002 F.A. Davis Company
ADDITIONAL INFORMATION Several nursing authors have recognized the interdependent na-
ture of illness and healing.105,107110 This interdependence is espe-
Some nursing authors object to the term Noncompliance.104107 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- benet 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 dif- The specic target dates for these objectives will be directly related
cult to follow through with it. The area of noncompliance must be to the barriers identied, the patients entering level of knowledge,
specied. A patient may follow many aspects of a treatment program and the comfort the patient feels in expressing satisfaction or dis-
very well and nd only a small part of the plan difcult to manage. satisfaction. The target date could range from 1 to 5 days following
Such a patient is noncompliant only in the area of difculty. the date of admission.
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Help the patient and/or family identify potential areas of conict, 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 patients 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 decits
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 conict 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 signicant 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 signicant others return-demonstrate or Allows sufcient 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 signicant others Demonstrates, in writing, the importance of the plan, and by listing
for specics regarding regimen. Have patient and family denitive follow-up times, enhances the probability of regimen
establish mutual goal setting sessions. Assign specic family implementation. Involvement increases motivation and improves
members specic tasks. Follow up 1 wk after discharge; the probability of success.
recheck 6 wk following discharge.
Design techniques that encourage the patients or familys 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 rst 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
reductions.
Teach the patient and signicant others assertive techniques that Long waiting periods in ofces, 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 patients 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 decits 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 patients leaving the Demonstrates exactly how to make appointments for patient.
hospital. Do it from the patients 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 23 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 childs health
the infants birth through emphasis of these aspects in childbirth before birth. Allows sufcient time for parents to incorporate these
education classes. ideas.
Allow for the infant or childs 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 specic planning and knowledge of condition
infant or childs 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
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Develop a sensitivity for cultural differences of womens roles Demonstration of understanding of the patients 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 womans and her familys 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.101103
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
nancial 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.101103
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 inuenced by a larger social
system and that this social system plays a crucial role in the clients 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
ACTIONS/INTERVENTIONS RATIONALES
Involve the client system in discussions on the treatment plan. Promotes the clients perceived control and increases potential for
This should include: the clients involvement in the treatment plan.
Family
Individuals the client identies as important in making
decisions related to health (e.g., cultural healers, social
institutions such as probation ofcers, public welfare
workers, ofcials 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 familys strengths, and
Questions to ask the family include: provides the nurse with an opportunity to support these strengths
What do you think is the difculty 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 identied 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 sacricing 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 Afrms and promotes clients 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 clarication 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 clients 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
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 familys sense of control and the development of a
obtained in the assessment. These goals should be specic 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
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 specic behavioral homework Suggesting specic 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 familys normal patterns. For example, have them start with
calling a resource for the information they may need to do
something different. If it is difcult 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 difcult 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 difculty 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 specic plan
Assist family in making these contacts by developing a specic increases opportunities for success.53,59
plan. Note the specic 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 familys accomplishments. Give Reinforces familys 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
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 difculty 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 ow 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 inuences 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 specic 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 decits 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
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 identication 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 identication 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 difcult for
service workers to reduce the number and variety of some clients to adhere to.
medications and treatments for chronically ill clients.117119
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
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?
No Finished
Copyright 2002 F.A. Davis Company
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX; Risk for Injury This diagnosis is broader
CLASS JPERIOPERATIVE CARE based than Risk for Perioperative-
Positioning Injury. The latter would only be
NOC: DOMAIN IFUNCTIONAL HEALTH; used when surgery is involved.
CLASS CMOBILITY 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
Will remain free from any signs or symptoms of perioperative-
RELATED FACTORS41 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 rst 2 days postoperatively.
2. Peripheral vascular disease
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
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 t the patients 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.
patients legs (up to mid thigh).
Pad popliteal space.
Ensure that the patients buttocks are over lower break in
table.
Nephro or Thoracic Surgery
Move the patient slowly and carefully, as a unit; have sufcient 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 patients sides with padded kidney rests. Provides support for side and back.
Bend bottom leg 4590 degrees. Top leg should be straight. Stabilizes the patient.
Place pillow(s) between knees and legs and feet. Protects pressure points.
Jacksonian (Modied Knee-Chest)
NOTE: Patient will probably be put to sleep on the stretcher and
then rolled onto the OR table.
Have sufcient 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 patients 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 patients position.
Copyright 2002 F.A. Davis Company
Child Health
NOTE: Any procedure requiring prolonged stabilization in a xed position places neonates and children
at risk for this diagnosis; e.g., ECMO (extracorporeal membranous oxygenation) with cannulation of ma
-
jor vessels requires xed positioning for several days to 1 week.
ACTIONS/INTERVENTIONS RATIONALES
Monitor skin integrity from head to toes with specic 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
Womens 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 mothers 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 mothers 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.120122
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
No Yes
No Finished
Copyright 2002 F.A. Davis Company
PROTECTION, INEFFECTIVE 75
4. Drug therapies (antineoplastic, corticosteroid, immune, antico-
Protection, Ineffective 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 11SAFETY/ 1. AIDS
PROTECTION; CLASS 2PHYSICAL INJURY 2. Diabetes mellitus
3. Anorexia nervosa
NIC: DOMAIN 4SAFETY; CLASS VRISK 4. Cancer
MANAGEMENT 5. Clotting disorders, e.g., disseminated intravascular coagulation,
thrombophlebitis, anticoagulant medications
NOC: DOMAIN IVHEALTH KNOWLEDGE AND 6. Substance abuse or dependence
BEHAVIOR; CLASS SHEALTH KNOWLEDGE 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. Decient 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 dening 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 proles (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.
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 signicant 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
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 patients 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 patients 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 signicant others: Provides basic knowledge needed for the patient and family to
Medication administration make modications 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 rst 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-Gurin (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 childs system by
Observable lesions of ecchymotic nature or evidence of infection, etc.
tendency toward bruising
Decreased absorption of nutrients (especially the premature
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 specic 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 childs 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.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Maintain monitoring for dening 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 signicant blood loss), and hypertension.86,102
(continued)
Copyright 2002 F.A. Davis Company
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.
Mothers 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 rst 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 clients 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 clients
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
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)
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
uids (use 1:10 solution of bleach)
Protective isolation
Proper handwashing
chemotherapy vials
Nutrition
Environmental cleanliness
Assist the client and the family to identify resources to meet Involvement of the client and family improves their ability to
identied 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 clients 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
Protection, Ineffective
FLOWCHART EVALUATION: EXPECTED OUTCOME
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.
No Finished
Copyright 2002 F.A. Davis Company
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.
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 patients food and uid intake daily. fatigue.
Carefully plan activities of daily living and daily exercise Realistic schedules based on the patients 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 patients
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
Challenge unrealistic assumptions or goals. Assists the patient to avoid placing extra stress on self.
Consider cultural and religious norms. Cultural and religious norms inuence 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 clients situation, with specic attention to medications, recovery.
formula or diet, and surgical procedure/expected recovery.
Note specic 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 identied. 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 identied as Multifactorial problems in recovery are best managed by separation
critical to resolution in relation to current surgical delay. and identication according to known etiology and treatment.
Womens Health
This nursing diagnosis pertains to women the same as to any other adult, with exception of the following:
ACTIONS/INTERVENTIONS RATIONALES
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 clients 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 clients 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
signicant others the benets 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 deciencies, 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
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 caregivers 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 clients 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
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?
Finished
CHAPTER 3
Nutritional-Metabolic Pattern
86
Copyright 2002 F.A. Davis Company
CONCEPTUAL INFORMATION 87
5. Is the patients uid intake sufcient for his or her age, sex, Conceptual Information
height, weight, activity level, and uid output?
a. Yes The nutritional-metabolic pattern requires looking at four separate
b. No (Decient Fluid Volume, Risk for or Actual; Imbalanced but closely aligned aspects: nutrition, uid 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 uid intake provides carbohydrates, proteins, fats, vi-
b. No tamins, and minerals, which are metabolized by the body to meet
7. Is the patients gag reex present? energy needs, maintain intracellular and extracellular uid bal-
a. Yes ances, prevent deciency syndromes, and act as catalysts for the
b. No (Impaired Swallowing; Risk for Aspiration) bodys 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 patients 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 inamed 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 patients teeth. Are teeth within normal limits? Swallowing is associated with the intake of food or uids. 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 rst two phases are voluntarily controlled, and the
13. Review the patients temperature measurement. Is the temper- last two phases are involuntarily controlled.
ature within normal limits? Many factors affect a persons 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 persons ability to eat.3
14. Is the patients temperature above normal? In essence, we are initially concerned with the adequacy or in-
a. Yes (Ineffective Thermoregulation; Hyperthermia) adequacy of the patients 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 patients temperature below normal? are dening adequacy in a similar manner. Most people probably
a. Yes (Ineffective Thermoregulation; Hypothermia) dene 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 deciency 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) 611 servings per day
b. No Vegetables 34 servings per day
The next questions pertain only to a mother who is breastfeeding. Fruits 24 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 23 servings per day
his or her age? Meat, poultry, sh, dry 23 servings of 23 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 reective 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 reect 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 uid contains the same number of elec-
(anorexia, bulimia), or cultural factors (lack of resources or reli- trolytes as the extracellular uid 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 uid. 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 uid and electrolytes created by all functioning as well as the uid 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 uid and nutri- through increasing or decreasing body uid 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 uids; 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 reects the acidity or alkalinity of body uids
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 uid, 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 uid
FLUID VOLUME loss, or increased uid intake. Because uid volume is so readily af-
fected by such a variety of factors, continuous assessment for alter-
Fluid volume incorporates the aspects of actual uid amount, elec- ations in uid volume must be made.
trolytes, and metabolic acid-base balance. Regardless of how much
or how little a patients intake or how much or how little a patients TISSUE INTEGRITY
output is, the uid, electrolyte, and metabolic acid-base balances
are maintained within a relatively narrow margin. This margin is es- Nutrition and uid 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 adults weight is body uid (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 bodys rst line of defense. The
75 percent of an infants weight is body uid. These various parts skin also plays a role in temperature regulation and in excretion.
of body uid 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-
uid 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) uids. 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) uid. Distribution of body uid is inuenced The skins supercial blood vessels and sweat glands (eccrine and
by both the uid volume and the concentration of electrolytes. apocrine) assist in thermoregulation. As the body temperature rises,
Body uid movement, between the compartments, is constant and the supercial 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 uid balance is regulated by intake (food and uid), 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 uid volume and osmotic
mones (antidiuretic hormones, glucocorticoids, and aldosterone). balance. As the body temperature drops, the opposite reactions oc-
The largest amount of uid 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 fulll 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 reex.
also allow uid 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 sufcient 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 babys learn-
dictive of increased risk for skin breakdown.7 Any factor that com- ing to swallow at other than a reex level.9 Tooth eruption begins
promises nutrition, uid, or electrolyte balance can result in at about 6 months of age and stimulates saliva ow 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 infants body
weight. Approximately 75 to 78 percent of an infants body weight
THERMOREGULATION is water, with about 45 percent of this water found in the extracel-
lular uid. The newborn infant loses signicant water through in-
Thermoregulation refers to the bodys 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 uid intake or uncompensated water loss.10
sponding to changes in electrolyte balances. Both the extracellular The body uid 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 decient
cium within the hypothalamus, hypothermia or hyperthermia can uid volume. The infant needs to consume uids 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 inuence 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 persons skin to vapor. Conduction is the loss of heat to lar ltration 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 infants 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 uid 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, uid 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.
The skin of an infant is functionally immature, and thus the baby
Developmental Considerations 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 chang and rub burns.9 Epidermal layers are permeable,
Swallowing is a reex present before birth, because during in- resulting in greater uid loss. Sebaceous glands, which produce se-
trauterine life the fetus swallows amniotic uid. 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 uid 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 uid every
tion remains minimal through childhood. The inability of the skin 24 hours, whereas the preschooler needs 1300 to 1400 mL of u-
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 uctuates 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 signicance 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 inuence 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 uid loss; the skin is not as soft as the infants,
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 signicant 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 childs 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 lm 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 uid 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
ers. 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 rst dental examination should be between the ages of 18 school-age child needs approximately 1.5 to 3 quarts of uid a day.
and 24 months. Dental hygiene should be started when the rst 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 avored with a few drops of mouth- phorus and calcium (because of bone growth).14
wash. After 18 months, the childs 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 reect 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 uid is about 26 percent, whereas the adult has about 19 school age child reects the nutritional experiences of early child-
percent extracellular uid. Toddlers have less reserve of body uid 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 uid 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 uid 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 difcult 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 tting 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 adolescents 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 inuence 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 difcult 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 uid being extracellu- Older adults have problems tolerating extremes of temperature. Ag-
lar. Growth is essentially nished by this developmental age. ing results in skin changes such as dryness and wrinkling. Skin as-
sessment for alterations in uid 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 inuence the amount of body water by directly al- membranes, sunken appearance of the eyes, or difculty
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 uids 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 specic 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 uid in the evenings to offset nocturia, but limiting uids 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, ber, and vitamin intake.29 uli, demonstrates difculty 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 withdrawalnoticeable 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 decitno 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. Difculty performing simple self-care tasks
changes in peripheral blood flow make older adults more sensi- 14. Neglects home environment and/or nancial 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 stateexpresses 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
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 decit effectiveness of therapy.
Occult blood in stools
Dehydration; replace with IV uids 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.
Womens 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 clients support system the clients
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.3335
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 difculty 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 clients 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 clients physical energy.36
reinforcement. Note here client-specic reinforcers.
When the clients 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 clients 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 adults 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 46 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 clients strengths, and provide the opportunity for resolution of
prior unnished conicts.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 signicant 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 uids with highuid content foods (e.g., popsicles, Prevents development or exacerbation of dehydration.
gelatin, and ice cream).
(continued)
Copyright 2002 F.A. Davis Company
96 NUTRITIONAL-METABOLIC PATTERN
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?
No Finished
Copyright 2002 F.A. Davis Company
98 NUTRITIONAL-METABOLIC PATTERN
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 reux 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 reexes. 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
the secretions.
she is swallowing.
Start with soft, nonacidic, noncrumbly foods rather than Liquids are more difcult to control.
liquids.
Discuss with the patient the purpose for any alterations in
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 uids 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 uid.
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 difculty (from mild to severe) will be noted.
Measure amount of residual, immediately before feeding, in Monitors the speed of digestion and indicates the patients ability
nasogastric tube and report any excess beyond 10 to 20 percent to tolerate the feeding.
of volume or as specied.
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
Womens Health
NOTE: The following actions pertain to the newborn infant in the presence of meconium in amniotic
uid.
ACTIONS/INTERVENTIONS RATIONALES
Alert obstetrician and pediatrician of the presence of meconium Presence of meconium alerts health care providers to possible
in amniotic uid. complications.
Assemble equipment and be prepared for resuscitation of the Basic emergency preparedness.
newborn at the time of delivery.
Be prepared to suction the infants 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 infants respiratory status. There is no designated time frame for observation; however, the
nurse needs to continue to evaluate the infant for at least 1224 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 reex and Basic safety measures until the client can demonstrate control.
swallowing have returned to normal. Monitor gag reex 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 inuence of
gravity on stomach contents.
Clients in four-point restraint should be placed on right side or Lessens probability of aspiration due to difculty in swallowing
stomach. Elevate the clients 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 reex. reex. Loss of this reex promotes the likelihood of aspiration.
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Older adults may develop a decreased gag reex. To reduce the Establishes baseline data to use for comparison after the procedure
risk of aspiration: is completed.
Monitor gag reex before any procedures involving anesthesia
such as bronchoscopy, esophagogastroduodenoscopy (EGD),
or general surgery.
Monitor gag reex post procedure before giving uids or solids. Ensuring return of gag reex 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
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?
No Finished
Copyright 2002 F.A. Davis Company
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
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 dened 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 98100F): 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
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient in identifying lifestyle adjustments necessary So-called hot ashes related to changes in the bodys 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 uctuate with
the aging process, some hot ashes will occur. These can be helped
by adjusting the environment, e.g., room temperature, amount of
clothing, or temperature of uids consumed.
Maintain house at a consistent temperature level of 7072F.
Keep bedroom cooler at night and layer blankets or covers that
can be discarded or added as necessary.
Have the patient drink cool uids, 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
bodys 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 difcult 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 clients 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
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.
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
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 99F for past 5 days. Record
RESOLVED. Delete nursing diagnosis,
expected outcome, target date, and
nursing actions.
Is diagnosis validated?
Finished
Adult Health
For this diagnosis, Womens 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
Womens Health.
Womens 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
ACTIONS/INTERVENTIONS RATIONALES
Review the mothers 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 signicant other with Successful lactation depends on understanding the basic how-tos
correct breastfeeding techniques, e.g., positioning and latch-on. and correct techniques for the actual feeding act.
Teach the mother and signicant 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 mothers 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 rst hour after birth unless It is important to work with the infants 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 mothers and
infants charts.
Encourage the mother and signicant 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 uids.
To provide sufcient 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 23 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 infants demands. understand the infants suckling will determine the supply and
demand of breast milk.
Monitor the infants 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 days activities when Helps the new mother establish a schedule that is benecial for
breastfeeding to ensure that the mother gets sufcient 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 signicant 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 Womens Health.
Copyright 2002 F.A. Davis Company
Breastfeeding, Effective
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?
No Finished
Copyright 2002 F.A. Davis Company
10. Infant exhibiting fussiness and crying within the rst hour
Breastfeeding, Ineffective 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. Insufcient opportunity for sucking at the breast
faction or difculty with the breastfeeding process.30
RELATED FACTORS30
NANDA TAXONOMY: DOMAIN 7ROLE 1. Nonsupportive partner or family
RELATIONSHIPS; CLASS 3ROLE PERFORMANCE 2. Previous breast surgery
NIC: DOMAIN 5FAMILY; CLASS W
3. Infant receiving supplemental feedings with articial nipple
CHILDBEARING CARE
4. Prematurity
5. Previous history of breastfeeding failure
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; 6. Poor infant sucking reex
CLASS KNUTRITION 7. Maternal breast anomaly
8. Maternal anxiety or ambivalence
DEFINING CHARACTERISTICS30 9. Interruption in breastfeeding
10. Infant anomaly
1. Unsatisfactory breastfeeding process 11. Knowledge decit
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 rst week of breastfeeding 1. Any diseases of the breast
6. Observable signs of inadequate infant intake 2. Cleft lip; cleft palate
7. Insufcient 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
Adult Health
For this nursing diagnosis, the Womens Health nursing actions serve as the generic nursing actions.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to the infants ability to suck: Assessment of the infants 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
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 pacier 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 mothers condence 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 mothers choice for whatever alternatives
are chosen.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Ascertain the mothers desire to breastfeed the infant through Provides intervention base for nursing actions. Allows planning of
careful interviewing and reviewing of the mothers 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.
reex. 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 mothers comfort, or using pillows for
supporting the baby.
(continued)
Copyright 2002 F.A. Davis Company
with breastfeeding
interaction
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 Womens 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
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 Identication 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
Breastfeeding, Ineffective
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
Finished
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Arrange care activities to facilitate the mothers 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 infants
caregiver during the time of the mothers hospitalization.
Provide privacy for the family.
Collaborate with diet therapist regarding mothers 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 34 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for infants 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 benecial 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 infants 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
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Provide appropriate information on why breastfeeding needs to Assists breastfeeding families in establishing and maintaining
be interrupted. Be specic 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.4345
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 mothers 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 ngers so as not to damage
breast tissue
milk
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 healthrelated 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 specically
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
Breastfeeding, Interrupted
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage well-balanced diet including ber. 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
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; signicant injuries or
exposures; and nutritional possibilities.
Determine whether there are coexistent congenital anomalies. Primary decits may exist in isolation or in combination with other
decits.
Identify current dental hygiene for the client (expectations Preventive maintenance knowledge offers a baseline for hygiene
according to age norms; e.g., 6 monthsgentle 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 identication of deviations.
for primary and secondary teeth.
Determine patterns of tooth loss according to norms for primary Expected norms assist in identication of deviations.
and secondary teeth.
Make appropriate recommendations for maintenance, Appropriate referral to specialists offers maximum potential for
prophylactic, and restorative care of the clients 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.
nancial, as determined on an individual basis.
Womens 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 caregivers 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
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 tting dentures when Decreases multiple problems created by poorly tting dentures.
necessary. Older clients will require correction of denture t
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 modications:
Reducing rened 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
Dentition, Impaired
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Measure and record total intake and output every shift: Determines uid loss and need for replacement.
Check intake and output hourly.
Observe and document color and consistency of all urine,
stools, and vomitus.
Check urine specic 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 uids. (See Additional Information for Monitoring of uid replacement and prevention of uid 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 uid 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 uid replacement. Allows consistent comparison
same time each day in same-weight clothing. of weight.
Force uids to a minimum of 2000 mL daily:
Ascertain the patients uid likes and dislikes [list here].
Offer small amount of uid (45 oz) at least every hour while
awake and at every awakening during night.
Offer uids at temperature that is most acceptable to the
patient, i.e., warm or cool.
Interspace uids with high-uid-content foods, e.g., popsicles,
gelatin, pudding, ice cream, or watermelon. Note the patients
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 uid loss without
verbal support for the patients consuming uid. resorting to IVs. Frequent uids improve hydration; variation in
uids 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 uids in any one part of body. Assists in
[state times here] while awake. circulation of uid.
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 uid 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 uid
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
Periods of exercise
Hot weather
Measures to ensure adequate hydration: Support the patients self-care by pointing out measures he or she
Need to drink uids before feeling of thirst is experienced can use to control uid 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
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 uid assessment is meaningful for diagnosing decits 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 specic gravity every 2 h on [odd/even] hour or Specic gravity is a good indicator of degree of hydration.
Force uids to a minimum appropriate for size (will be closely Prompt replacement and maintenance of appropriate uids
related to electrolyte needs and cardiac, respiratory, and renal prevents further circulatory or systemic problems. Specic
status): attention is also required with respect to sodium, potassium, and
Infants: 70100 mL/kg in 24 h caloric intake. Infants are subject to uid volume depletion
Toddler: 5570 mL/kg in 24 h because of their relatively greater surface area, higher metabolic
School-age child: 2050 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 patients 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.
Womens 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 patients support system.
Monitor the patients feelings (positive or negative) about
pregnancy.
Evaluate social, economic, and cultural conditions.
Involve signicant 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 fetuss needs.
(continued)
Copyright 2002 F.A. Davis Company
empty stomach).
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 1216 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
dehydration.57)
vitamin supplements
been found effective and safe for use in nausea and vomiting
of pregnancy.5)
bottle formula.
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 clients
place on intake and output measurement, and record this ability to recognize need for uids.
information every shift.
Evaluate potential for uid decit resulting from medication or Estimated daily requirement for adults is 15003000 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 clients ability to independently
take uids.
If the clients values and beliefs inuence intake:
Alter environment as necessary to facilitate uid intake, and
drink on unit.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the patient to drink at least 8 oz of uid every hour Older adults with cognitive decits may forget to consume liquids.
while awake. Prompting such patients to drink uids should be an essential part
of their plan of care.
Be sure uids are within reach of the patient conned to bed. For those conned to bed or with restricted movement, this action
is a simple, basic measure to promote uid 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 uid retention or high blood pressure
Confusion or lethargy
Fever
Excessive blood loss
Wound drainage
Inability to obtain adequate uids because of pain,
immobility, or difculty in swallowing
Assist the client and family in identifying lifestyle changes that Avoidance of dehydrating activities will prevent excessive uid 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
Yes No
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
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 uid 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 uid retention and need for uid
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 specic gravity at least every 2 h on [odd/even] hour.
Monitor: Essential monitoring for uid 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.
Weigh daily at [state times here]. Monitoring for uid 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 uids prevents cardiovascular system overload and
Amount reduces workload on renal system.
Type, e.g., clear uids only or intravenous only
Turn and properly position the patient at least every 2 h on Prevents stasis of uids in any one part of body. Assists in
[odd/even] hour. circulation of uid 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 uid allowed.
Teach the patient to monitor own intake and output at home. Supports the patients self-care by pointing out measures he or she
can use to control uid 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 (80100 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 specic gravity assists in
Monitor specic gravity at least every 2 h or as specied. determining cardiac, renal, and respiratory function and electrolyte
status.
(continued)
Copyright 2002 F.A. Davis Company
Womens 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 rst 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 clients 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
therapy)
Deep tendon reexes (DTR) at least every 4 h [state times Basic safety measures.
here]
[odd/even] hour
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 include5961: dopamine central nervous system activity and dysfunction in
Frequent trips to sources of uid and excessive consumption antidiuretic hormone activity in combination with psychosocial
of uids 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 uctuations in weight
Polyuria
Incontinence
Carrying large cups
Urine specic gravity of 1.008 or less59
Decreases in serum sodium
(continued)
Copyright 2002 F.A. Davis Company
Provide small medicine cup (30 mL) for the client to obtain
uids.
Provide uids 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 clients preference.
Identify with the client those activities that would be most
helpful in diverting attention from uid restriction. Note
specic activities here with schedule for use.
Refer to occupational and recreational therapists.
If the client continues to have difculty restricting uids,
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 clients restriction in a community meeting if:
Restrictions are impacting others on the unit.
Support from peers would facilitate clients maintaining
restrictions.
Provide positive verbal support for the clients maintaining Promotes the clients self-esteem and provides motivation for
restriction(s). continued efforts.
Identify with the client appropriate rewards for maintaining Promotes the clients 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 Identication of risk factors and understanding of relationship to
the situation, e.g., heart disease, kidney disease, diabetes mellitus, uid excess provide for intervention to reduce or prevent negative
diabetes insipidus, liver disease, pregnancy, or immobility. outcomes.
(continued)
Copyright 2002 F.A. Davis Company
Avoid excess salt. Teach the patient and family to read labels
Weigh at the same time every day wearing the same clothes
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
Yes No
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
A risk of a decrease, increase, or rapid shift from one to the other RISK FACTORS30
of intravascular, interstitial, and/or intracellular uid. This refers to
the loss or excess or both of body uids or replacement uids.30 1. Scheduled for major invasive procedures
2. Other risk factors to be determined
NANDA TAXONOMY: DOMAIN 2NUTRITION;
CLASS 5HYDRATION RELATED CLINICAL CONCERNS
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Measure and record total intake and output every shift. Determines uid loss or uid retention and need for replacement
or restriction of uids.
Check intake and output hourly.
Observe and document color and consistency of all urine, stools,
and vomitus.
Check urine specic 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 uids.
Monitor: Essential monitoring for uid 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 uid 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
tachycardia or tachypnea
Weigh daily at [state time here]. Teach the patient to weigh at Monitoring for uid replacement. Allows consistent comparison
same time each day in same-weight clothing. of weight.
If there is a uid volume decit, force uids to a minimum of
2000 mL daily.
Determine the patients uid likes and dislikes. (List here.) Prevents dehydration and easily replaces uid loss without
Consult with dietary. resorting to IVs.
Offer small amount of uid (45 oz) at least every hour while Frequent uids improve hydration. Variation in uids is helpful to
awake and at every awakening during night. encourage the patient to increase intake.
Offer uids at temperature that is most acceptable to the
Check dependent parts for edema, e.g., ankles, sacral area, and
buttocks.
If there is uid volume excess, collaborate with physician about Restricting uids prevents cardiovascular system overload and
restricting uids. 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 uids in any one part of body. Assists in
circulation of uid 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 uid volume imbalances with infants
children scheduled for surgery or procedures in which NPO or children who undergo surgery during which uids 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 decit
ongoing uid plan for the client with specications for: or overload for vulnerable infants and children in advance of actual
Type of uid and status of oral feedings occurrence.
Rate of administration of IV uid
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 specic gravity record
Identify appropriate parameters to be addressed by all members Pre-identication of coordination of multidisciplinary specialists
of the health care team during and after surgery or procedure to assists in appropriate uid maintenance.
include cardiac, renal, neurologic, metabolic, and related
physiologic alterations.
(continued)
Copyright 2002 F.A. Davis Company
Womens 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 ow 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 difcult. 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 uid overload and hyponatremia. Postoperatively, the older adult may have ex-
cessive or prolonged aldosterone/ADH responses, causing difculty eliminating excess uids.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the client for the presence of ascites (e.g., abdominal Prevents complications of uid shifts.
distention with weight gain) or edema and report to physician.
Monitor for signs of dehydration: Dehydration may accompany uid 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 uid balance.
adhering to a sodium-restricted diet (e.g., 250500 mg per day).
Educate the client and caregivers about medications prescribed Promotes compliance with prescribed medications.
to control the uid 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 identication of progressing uid imbalances.
Copyright 2002 F.A. Davis Company
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.
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 manufacturers
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 uid and electrolyte balance.
vomiting.
Encourage uids up to 3000 mL every 24 h. Helps maintain uid and electrolyte balance and assists in
replacing uid 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
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
specied provides cues to evaluate efcacy 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 childs age and weight
Potential untoward response
IV compatibility
The infants or childs 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
Womens Health
NOTE: Newborn is included with Womens 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 infants temperature, skin turgor, and fontanels Provides essential information as to the infants 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 infants physiologic functioning.
every 24 h.
Replace lost uids by offering the infant breast, water, or Decreases insensible uid loss and maintains body temperature
formula at least every 2 h on [odd/even] hour. within normal range. This action decreases the infants 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 rst trimester: Concerns about possible CNS
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 clients 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 clients uid 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 clients favorite uids on the unit.
(2) Having the client drink 240 mL (an 8-oz glass) of uids
every hour while awake and 240 mL with each meal. If
necessary, the nurse will sit with the client while the
uid is consumed.
(3) Maintaining record of the clients 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 clients
observation. ability to make proper judgments.
(continued)
Copyright 2002 F.A. Davis Company
HYPERTHERMIA 143
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Decrease the clients 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 bodys normal adaptive response.58
client in a table game or activity that requires little large
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 Dening Identication 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.
Hyperthermia
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., rectal temperature Reassess using initial assessment factors.
measurement has ranged from 98 to
100F for past 4 days. Record
RESOLVED. Delete nursing diagnosis,
expected outcome, target date, and
nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
HYPOTHERMIA 145
8. Slow capillary rell
Hypothermia 9. Tachycardia
DEFINITION
RELATED FACTORS30
The state in which an individuals body temperature is reduced
below normal range.30 1. Exposure to cool or cold environment
2. Medications causing vasodilation
NANDA TAXONOMY: DOMAIN 11SAFETY/ 3. Malnutrition
PROTECTION; CLASS 6THERMOREGULATION 4. Inadequate clothing
5. Illness or trauma
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX; 6. Evaporation from skin in cool environment
CLASS MTHERMOREGULATION 7. Decreased metabolic rate
8. Damage to hypothalamus
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; 9. Consumption of alcohol
CLASS IMETABOLIC REGULATION 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
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Warm the patient quickly. Use blankets, warming blankets, Basic measures that assist in increasing core temperature and
warm water (102105F), 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
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
Difculty 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, nancial 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 nancial counseling if heating the home is
nancially difcult.
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 patients 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.
Womens 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 specic 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 112 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 mothers body (cover the mother and the
infant by placing blanket over them).
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the clients 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 rst 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
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)
HYPOTHERMIA 149
Hypothermia
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 75F,
uses electric blanket. Record
RESOLVED. Delete nursing diagnosis,
expected outcome, target date, and
nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
For this diagnosis, Child Health and Womens 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.
difculties 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 Specic criteria provide measurable progress parameters.
(continued)
Copyright 2002 F.A. Davis Company
or gastric tube
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 infants progress in tolerance of feeding and feeding
efcacy.
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 infants needs. care.
Allow for appropriate time to prepare the infant for feeding, and A nonhurried, nonstressful milieu promotes the infants 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-condence and coping.
Provide teaching based on an assessment of parental knowledge Knowledge provides a means of decreasing anxiety. When based on
needs and/or decits. assessed needs, it will reect the individualized needs and more
likely meet the parents 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.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Provide support and information to the mother and signicant The basic rationale for all the nursing actions in this diagnosis is to
other. Explain the infants 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.6466
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 68 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 signicant 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 Womens Health.
Copyright 2002 F.A. Davis Company
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?
No Finished
Copyright 2002 F.A. Davis Company
NAUSEA 153
3. Irritation to the gastrointestinal system
Nausea 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 12COMFORT; 4. Viruses
CLASS 1PHYSICAL COMFORT 5. Pregnancy
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC;
CLASS EPHYSICAL COMFORT PROMOTION
NOC: DOMAIN VPERCEIVED 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 uid
1. Chemotherapy and electrolyte imbalance, target dates should be at 24-hour inter-
2. Postsurgical anesthesia vals until the nausea is controlled.
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 uids 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.7176
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
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.
irritation/deviations, etc.)
Subjective data from all who have inuence 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 identication 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 specic 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,
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 childs sense of self-worth and likelihood of creating the best effort for self-worth of the infant or child and the
cooperation. parent.
Womens 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 adults 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.
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
Nausea
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
Finished
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Increase food and uid 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
patients 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 23 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 uid intake between meals:
Limit uid 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 uids 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 signicant 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 uid 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 patients 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 specic gravity,
and glucose level at least once per shift
(continued)
Copyright 2002 F.A. Davis Company
protein)
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 patients 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 verication
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 reux.
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-Fowlers position for at least 30 min Prevents reux 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.
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 uid
ow through stomach.
Monitor infusion rate at least every 4 h around the clock at Ensures that correct ow rate is being maintained.
[times].
(continued)
Copyright 2002 F.A. Davis Company
Intravenous
ACTIONS/INTERVENTIONS RATIONALES
Check insertion site for warmth, redness, swelling, leakage, and Basic monitoring for inltration and venous irritation.
pain at least every 4 h at [state times here].
Check ow rate at a maximum of every hour on the Prevents uid 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 agencys stated standard or policy. Implementation of Centers for Disease Control and Prevention
(CDC) guidelines; prevention of complications from tubing.
ACTIONS/INTERVENTIONS RATIONALES
Do not administer without pump. The pump allows for accurate ow rate.
Change tubing and lter daily at [state time here]. Ensures proper ow 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 specically how
heremost agencies have specic policy).
Check insertion site for warmth, redness, swelling, leakage, and Basic monitoring for inltration 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 patients status demands. Also, there will undoubtedly be instances in
which overlap may exist for other nursing diagnoses. Specically, 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 specic nursing process components to reect 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 (23 oz steady, incremental time frame.
every 23 h) than an infant of 15 lb (45 oz every 34 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 patients status and presence of various tubes and considered in each parent-child unit.
equipment.)
(continued)
Copyright 2002 F.A. Davis Company
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 efcacy 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
relationships.
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 condence
for ultimate self-care management with minimal intervention by
others.
Womens Health
NOTE: Poverty and substance abuse are often associated with nutritional decits. 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 rst 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,
sh, 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 patients means
and according to the patients particular needs and habits.
Determine whether weight loss during rst 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
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 mothers energy levels and health maintenance:
Does she complain of fatigue?
Does she have sufcient energy to complete her daily
activities?
Is she more than 10 percent below the ideal weight for her
body stature?
For breastfeeding the newborn or neonate during the rst 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 uid decit 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 uid intake and avoid nipple confusion.51,52 breastfeeding mother.63
Count number of diapers per day (should have 68 really
wet diapers per day).
Psychiatric Health
NOTE: Because of long-term care requirements for these clients, target dates should be determined in
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 specic 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.
specic 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 clients 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 clients 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 clients 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 clients 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 (specic 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 clients family by [list specic 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 difcult 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
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
mealtime.
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
Body Requirements
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.
No Finished
Copyright 2002 F.A. Davis Company
NUTRITION, IMBALANCED, MORE THAN BODY REQUIREMENTS, RISK FOR AND ACTUAL 167
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to identify dysfunctional eating habits, during Provides basic information needed to plan changes in
rst day of hospitalization, by: dysfunctional habits to begin weight-loss program.
Reviewing 1 weeks 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 weeks exercise pattern
Check activity level against daily dietary intake.
Discuss with the patient potential or real motivation for desiring Assists in understanding the patients 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 patients intake to number of calories recommended Reduces calories to promote weight loss yet maintain bodys
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 uid balance. A
low-calorie, caffeine-free drinks. signicant amount of weight loss in the rst few days is due to
uid 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 patients 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 rst 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
112 blocks from car to ofce.
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
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
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.
patients adhering to diet. Caution against bringing food, etc.
from home.
Discuss with the patient and signicant others the necessary
alterations in eating behavior, and develop a list of ways the
signicant others can be supportive of these alterations.
Use appropriate behavior modication 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 patients 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 patients 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 nal 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
patients positive orientation.86,87
Suggest that the patient contract with a signicant 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 difculty 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 patients 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 patients
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
identied 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 signicant
otheranything 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 specic to the child according to the childs develop-
mental level.
Copyright 2002 F.A. Davis Company
Womens 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 womans 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
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:
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 exibility exercises and aerobic activity
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-tting 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
Lifestyle changes
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for lesions or infectious processes of the mouth and Lesions or ulcers in the mouth promote difculty in swallowing.
oropharynx at least once per shift.
Test, prior to every offering of food, uid, etc., for presence of To prevent choking and aspiration.
gag reex.
Prior to offering food or uids, 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 patients room.
Support hydration and caloric intake. Collaborate with Maintains uid 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 uids before offering to the patient. Warm uids 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 difculty in swallowing.
Be supportive to the patient during swallowing efforts. Swallowing difculty is very frustrating for the patient.
Consult with nutritionist about the patients 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 patients 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributory factors, especially palate formation, A thorough assessment will best identify those patients who have
possible tracheoesophageal stula, or other congenital anomalies. greater-than-usual likelihood of swallowing difculties due to
Maintain the infant in upright position after feedings for at An upright position favors, by gravity, the digestion and absorption
least 112 h. of nutrients, thereby decreasing the likelihood of reux and
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 manufacturers elixir or suspension form of the
drug lessens the likelihood of impaired swallowing.
Womens 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 specic 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 clients 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 clients 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
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 ll mouth too full, and CPR
Swallowing, Impaired
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.
No Finished
Copyright 2002 F.A. Davis Company
5. Hypertension
Thermoregulation, Ineffective 6. Increased respiratory rate
DEFINITION 7. Pallor (moderate)
8. Piloerection
The state in which the individuals temperature uctuates between 9. Reduction in body temperature below normal range
hypothermia and hyperthermia.30 10. Seizures or convulsions
11. Shivering (mild)
NANDA TAXONOMY: DOMAIN 11SAFETY/ 12. Slow capillary rell
PROTECTION; CLASS 6THERMOREGULATION 13. Tachycardia
14. Warm to touch
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX;
CLASS MTHERMOREGULATION RELATED FACTORS30
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; 1. Aging
CLASS IMETABOLIC 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
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor vital signs at least every hour on the [hour/half-hour]. Monitors basic trends in temperature uctuations. 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Protect the child from excessive chilling during bathing or Evaporation and signicant change of temperature for even short
procedures. periods of time contribute to heat loss for the young child or
Assist in answering the parents or childs 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 specically to and their concerns. Specic 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 childs 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.
Womens 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 uctuating 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
Thermoregulation, Ineffective
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., oral temperature Reassess using initial assessment factors.
has remained between 97 and 99F
for past 5 days. Record RESOLVED.
Delete nursing diagnosis, expected
outcome, target date, and nursing
actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
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 signicant 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
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 nger.
Floss teeth.
solution).
(continued)
Copyright 2002 F.A. Davis Company
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 otation 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 uids: Adequate hydration assists in normal homeostatic mechanisms that
Infants: 250300 mL/24 h affect the skins integrity.
Toddler: 11501300 mL/24 h
Preschooler: 1600 mL/24 h
(These are approximate ranges. The physician may order
specic amounts according to the childs age and condition.)
(continued)
Copyright 2002 F.A. Davis Company
Womens 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 rst
812 h after delivery to reduce edema and increase comfort
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
(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
Womens 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 womens
health area. Focus needs to be made on the newborn simply
because the newborns 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 uoride
Proper use of paciers
Do not use homemade paciers
Use paciers 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
bottle.
(2) Wean child from bottle to cup soon after rst birthday.
(3) When continuing to nurse the infant, give water in cup
(5) Not place the infant on sheets where the mother has been
sitting.
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 specic areas for long periods of
parts. time, thus decreasing risk for breakdown.
Change the clients position every 2 h on [odd/even] hour.
Offer the client uids every 15 min. List preferred uids 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 uids 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.
Talk with the client in calm, quiet voice and use the clients
name.
Use restraints that are wide and have padding. Make sure
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-inicted injuries hourly for the rst 24 h for signs Early identication and treatment of infection can prevent more
of infection and further damage. Note information on a ow serious damage.
sheet. After the rst 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
ow 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
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 patients 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
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 uids, mild soap for
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.
Finished
CHAPTER 4
Elimination Pattern
b. No
10. Has number of bowel movements increased?
a. Yes (Diarrhea)
Pattern Assessment 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
put is affected by the amount of uid 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 infants 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 rst 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 rst 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 articial 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 rst 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 ora 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 teenagers 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
rst; 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 inuenced 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 uid 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 uids at night, have the child void before go- of intestinal disorders, cancer, and gastrointestinal complaints.
Copyright 2002 F.A. Davis Company
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 nd 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 reex with circular movement in rectum
using gloved, lubricated nger.
Teach the patient, beginning as soon after admission as possible: Basic knowledge promotes understanding of condition and assists
Pelvic oor strengthening exercises (see Constipation) the patient to change behavior as well as empowering the patient for
Diet, i.e., role of ber and uids 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. Modications would
be made for childs age and size, for example, medication dosage and uid amounts.
Womens 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 Womens Health are the same as in Adult Health.
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
If a pattern forms around specic events, develop plan to: Promotes the clients perceived control, and increases potential for
Encourage the person to use bathroom before the event. the clients involvement in treatment plan.
Alter the manner in which specic task is performed to
prevent stress [note alterations here].
Discuss with the client alternative ways of coping with stress.
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 clients awareness of impact inappropriate coping
behaviors have on lifestyle. Provides data for development of
alternative coping, promoting the clients perceived control.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Record events associated with incontinent episode. Assists in determining pattern of incontinence. Older adults may
have difculty 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 difculty nding a bathroom that is not
the individual to toilet may result in continence. readily identied.
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 oor 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
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.
Finished
3. Physiologic b. Pregnancy
a. Insufcient ber intake c. Rectal anal stricture
b. Dehydration d. Postsurgical obstruction
c. Inadequate dentition or oral hygiene e. Rectal anal ssures
d. Poor eating habits f. Megacolon (Hirschsprungs disease)
e. Insufcient uid 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-inammatory 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
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 ssures
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 uid balance.
include estimation of loss by perspiration.
Force uids, of patients choice, to at least 2000 mL daily. Increases moisture and water content of feces for easier movement
Encourage 8 oz of uid every 2 h on [odd/even] hour beginning through intestines and anus.
at awakening each morning.
Increase the patients 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 oor 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 oor
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 reex and urge.
after meals) [state times here].
Provide privacy and sufcient 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 atus.
on [odd/even] hour, for problems with atulence.
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 patients 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 reex through drinking prune juice
or hot liquid upon arising
To allow sufcient time for bowel movement and plan time
for elimination
To include high-ber 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
Child Health
Nursing actions for Constipation in the child are the same as those for Adult Health. Modications would
be made for childs age and size, for example, medication dosage and uid 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 identication of cause of constipation in case of
Hirschsprungs disease (congenital aganglionic megacolon) Hirschsprungs disease will offer appropriate treatment.
Neonatal period:
(1) Failure to pass meconium in rst 2448 h after birth
(2) Reluctance to ingest uids
(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 identication 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
Womens 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 mothers body uid intake to produce
lactation can lead to decrease in uid 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 inuences (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 atulence
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 uids, 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 oor 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-ber, 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
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 denition of constipation. Nursing interventions for physiologic denition 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 denition or is based on physiologic denitions 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, rened foods
Identication of any food intolerances or allergies and
avoidance of those foods
over-the-counter medications
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?
No Finished
Copyright 2002 F.A. Davis Company
2. Situational
Diarrhea a. Alcohol abuse
DEFINITION b. Toxins
c. Laxative abuse
Passage of loose, uid, unformed stools.15 d. Radiation
e. Tube feedings
NANDA TAXONOMY: DOMAIN 3ELIMINATION; f. Adverse effects of medication
CLASS 2GASTROINTESTINAL SYSTEM g. Contaminants
h. Travel
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC; 3. Physiologic
CLASS BELIMINATION MANAGEMENT a. Inammation
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; b. Malabsorption
CLASS FELIMINATION c. Infection process
d. Irritation
e. Parasites
DEFINING CHARACTERISTICS15
1. Hyperactive bowel sounds RELATED CLINICAL CONCERNS
2. At least 3 loose stools per day
3. Urgency 1. Inammatory bowel disease (ulcerative colitis, Crohns 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
DIARRHEA 207
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 uid 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 uid intake to at least 2500 mL per day. Maintains hydration status.
Offer uids high in potassium and sodium at least once per
hour, e.g., Gatorade, Pedialyte.
Serve uids at tepid temperature (avoid temperature extremes
such as very hot or very cold).
List the patients uid 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 patients 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-ber, 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 patients knowledge of causes, treatment, and
Diet: avoiding irritating foods, including basic food pyramid complications of diarrhea. Promotes self-care.
groups, inuence of high-ber foods, and inuence of fruits.
Fluids: maintaining intake and output balance, inuence of
e.g., antacids.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Weigh diapers for urine and stools, assess specic gravity after A strict assessment of intake and output serves as a basis for
each voiding. monitoring the efcicacy of the treatment and may provide a
database for treatment protocol. Hydration is monitored via specic
gravity as an indication of the renal ability to adjust to uid 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, atus, 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 specic formula or diet
Monitoring electrolytes and renal function
Maintenance of IV uids
Antidiarrheal medications
Womens 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 clients adaptive response to stress, and promotes the
specic interventions 3 times a day at [list times here]. clients sense of control.
Refer to Chapter 8 for specic 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 uid and electrolyte balance
(see Adult Health)
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).
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
Diarrhea
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
No Finished
Copyright 2002 F.A. Davis Company
3. Decreased bladder capacity (for example, history of pelvic in- RELATED CLINICAL CONCERNS
ammatory disease, abdominal surgeries, or indwelling uri-
nary catheter) 1. Spinal cord injury
4. Increased uids 2. Urinary tract infection
5. Increased urine concentration 3. Alzheimers 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.
ACTIONS/INTERVENTIONS RATIONALES
Record: Monitors voiding pattern and effectiveness of treatment.
Time and amounts of each voiding
Whether voiding was continent or incontinent
The patients 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 patients 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 rst)
Having the patient listen to dripping water
Placing the patients hands in warm water
Using Creds 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 rm towel roll when incontinence threatens
Gradually increasing length of time, by 15 min, between
voidings
Schedule uid intake: Assists in predicting times of voiding. Decreases urge to void at
Avoid uids containing caffeine and other uids that produce unscheduled times.
a diuretic effect (e.g., coffee, grapefruit juice, and alcohol).
Encourage 8 oz of uid every 2 h on [odd/even] hour during
the day.
Limit uids 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
voiding
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 oor
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
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 reux or recurrent potential urinary tract
Womens 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 oor musculature Strengthening of pelvic oor 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 benets of estrogen Loss of estrogen after menopause contributes to weakening of
replacement therapy. pelvic muscle bers.
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 Identies 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 specic 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 identied 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
specied time [list identied activities here].
(continued)
Copyright 2002 F.A. Davis Company
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 physicians 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 uids to cause voiding every 23 h to ush out bacteria
Scheduling uid 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 oor muscles
Providing an environment conducive to continence
Wearing street clothes and protective underwear
Using an air purier
Performing activities as tolerated
Providing unobstructed access to bathroom
Avoiding uids 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 uids
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
FLOWCHART EVALUATION: EXPECTED OUTCOME
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?
No Finished
Copyright 2002 F.A. Davis Company
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 uid balance.
Maintain uid intake: Ensures sufcient uid intake, but restricts uid when activity
Encourage uids to at least 2000 mL per day. decreases. Assists in preventing nocturia.
Limit uids 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 reex every 4 h while awake at [times]: Helps relax sphincter and strengthens voiding reex.
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
voiding
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 uid requisites according to the etiologic factors present. Attention must be paid to the
childs 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 patients 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
Womens 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 2448 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 clients 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 specic exercises to
times here] strengthen pelvic oor muscles).
Collaborating with physical therapist regarding an exercise
program
Placing the client in a room distant from the day area,
contraindicate this
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
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-
cians 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 reex (see Adult Health).
Institute bladder-retraining program.
Perform exercises to strengthen pelvic oor muscles.
Use proper position for voiding.
Maintain uid 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.
specied 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
Review chart for past 48 hours. Interview the patient. Is the patient
voiding under voluntary control?
Yes No
Yes
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 5
Activity-Exercise Pattern
224
Copyright 2002 F.A. Davis Company
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
result, the individual experiences orthostatic hypotension.4
Conceptual Information 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-
rst 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 efciency 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 dened 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 dene 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 cic medical diagnoses, such as congestive heart failure, or may oc-
and expressions. A problem with mobility can be a measure of the cur as a result of diagnoses in this pattern, for example, Delayed
degree of illness or health problem an individual has.3 Growth and Development. However, the concept of immobility
Patients with self-care decits 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, decient diversional activity, and impaired home factors that inuence 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 signicant 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 authors35 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 reex 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 ow, 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 inuence 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 specically 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 uids. 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 uence physical and motor abilities. Nutrition, maturation of the
Copyright 2002 F.A. Davis Company
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 ow. The capillary bed has increased ability to respond to environ-
312 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 toddlers chest should be examined with the child in
velopment of ne 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 childs 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 yearsfaster 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 312 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, exibility, 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 inuenced 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 reective
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 reect issues other than a self-care decit, for example, disci- Neuromuscular coordination is sufcient 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 ngers 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 signicance 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 nger 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 inam-
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
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-oor 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 reex,
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 ow. 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 bodys 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. Calcication 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- difcult for the older adult to have rapid and efcient 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.
ed 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 adults sense of well-being. Research in the
signicantly affect the ability of the family unit to maintain the 1990s has shown the benets 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 nding
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
4. Sedentary lifestyle
CLASS 4CARDIOVASCULAR/PULMONARY
RESPONSE
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 specic progress may be
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Provide learning modules and practice sessions with materials Developmentally appropriate materials enhance learning and
suitable for the childs age and developmental capacity, e.g., maintain the childs 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 patients 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.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
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 ow 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
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
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 rst 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 clients 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 tness 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 benets 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
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 clients
here.
Establish a reward system for achievement of goals (the Positive reinforcement encourages appropriate behavior.32
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 rm support for initiating the activity. Attention from the nurse can provide positive reinforcement and
increase the clients 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 clients illness and the family
client and the clients 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
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 sufcient support to achieve.
may be required:
Progressive exercise to increase endurance
Range of motion (ROM) and exibility 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 uids
Stress management
Pain relief
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
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?
No Finished
Copyright 2002 F.A. Davis Company
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
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 airow or lung volume is improved
patients 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 uid 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 patients favorite uids available:
Remind the patient to drink uids at least every hour while
awake.
Provide warm or hot drinks instead of cold uids.
Assist the patient in coughing, hufng, 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 35 s.
(continued)
Copyright 2002 F.A. Davis Company
procedure).
diaphragm
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
Choking, coughing
Flaring of nares
Provide appropriate attention to suctioning and related Ensures basic maintenance of airway and respiratory function.
respiratory maintenance: Gives priority attention to the childs status and developmental level.
Appropriate size for catheter as needed
Appropriate administration of humidied oxygen as ordered
by physician
min for an infant or 90 or 120 beats per min for a young
child
Encourage the parents 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,
childs situation. practicing of techniques, etc. before discharge. Assists in
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 satises 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 identied in Greater success in compliance and condence is afforded by
care of the child. providing ample time for skills that require mastery.
Womens 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 newborns airway. Deep suctioning
Suction and clear mouth and pharynx with bulb syringe. would stimulate reexes that could result in aspiration.
Avoid deep suctioning if possible.
Continue to evaluate the infants respiratory status, and act if Basic protocol for the infant who has difculty immediately after
necessary to resuscitate. Depending on the infants 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.
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 u 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 aring
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 uid
balance
(3) Postural drainage
(continued)
Copyright 2002 F.A. Davis Company
decreased
Suctioning as needed
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
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?
No Finished
Copyright 2002 F.A. Davis Company
5. Musculoskeletal-integumentary stimuli
Autonomic Dysreexia, Risk for and Actual a. Cutaneous stimulation (e.g., pressure ulcer, ingrown
DEFINITIONS21 toenail, dressings, burns, rash)
b. Pressure over bony prominences or genitalia
Risk for Autonomic Dysreexia 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 Dysreexia 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 uctuations
NANDA TAXONOMY: DOMAIN 9COPING/STRESS b. Extreme environmental temperatures
TOLERANCE; CLASS 3NEUROBEHAVIORAL STRESS 7. Situational stimuli
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX; a. Positioning
CLASS INEUROLOGIC MANAGEMENT b. Drug reactions (e.g., decongestants, sympathomimetics,
vasoconstrictors, narcotic withdrawal)
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; c. Constrictive clothing (e.g., straps, stockings, shoes)
CLASS JNEUROCOGNITIVE d. Surgical procedure
8. Cardiac and/or pulmonary problems
DEFINING CHARACTERISTICS21 a. Pulmonary emboli
b. Deep vein thrombus
A. Risk for Autonomic Dysreexia B. Autonomic Dysreexia
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 conned 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. Horners 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 reex (gooseesh formation when skin is
f. Difcult passage of feces cooled)
g. Constipation
h. Enema RELATED FACTORS21
i. Gastrointestinal system pathology
j. Gastric ulcers A. Risk for Autonomic Dysreexia
k. Esophageal reux The risk factors also serve as the related factors.
l. Gallstones B. Autonomic Dysreexia
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
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor vital signs, especially blood pressure, every 35 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 dysreexia, Finding precipitating causes prevents worsening of condition and
e.g., bladder distention (7690 percent of all instances), bowel allows further prevention of dysreexia.
distention (8 percent of all instances),4547 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 Creds 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 dysreexia.
Collaborate with physician regarding daily monitoring of Maintains uid 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
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 familys understanding and perception of the Assists in preventing misunderstandings and in identifying learning
problem. Ensure that proper attention is paid to the familys 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).
Womens 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.
Start an intravenous line for replacement of lost uid 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
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 Dysreexia4749: of dysreexia. Promotes sense of control and autonomy.
Bowel and bladder routines
Prevention of skin breakdown (e.g., turning, transfer, or
prevention of incontinence)
Prevention of infection
Assist the client and family in identifying signs and symptoms Provides for early recognition and intervention for problem.
of Autonomic Dysreexia47:
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 patients 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 dysreexia to be alert for signs and
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 briey 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 Dysreexia, problems, and recommended
treatment.
Copyright 2002 F.A. Davis Company
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?
No Finished
Copyright 2002 F.A. Davis Company
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 patients 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
patients 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 patients head.
Next, position your forearms under the patients 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
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributing factors within the clients 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 clients Ongoing timely assessment ensures safety and prevents injury.
tolerance of mobility activities as often as the patients 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.
Womens Health
The nursing actions for Womens 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
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
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?
No Finished
Copyright 2002 F.A. Davis Company
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.
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
Position of comfort
Breath sounds
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 specic 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 patients 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 515 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 patients 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
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient and signicant other in identifying lifestyle Increased cardiovascular tness supports increased respiratory
changes that may be required to prevent Ineffective Breathing effectiveness.
Pattern during pregnancy, e.g., stopping smoking or avoiding
crowds during inuenza epidemics.
Develop exercise plan for cardiovascular tness during pregnancy.
Teach the patient to avoid wearing constrictive clothing during Any constriction contributes to further breathing difculties, and
pregnancy. breathing becomes more difcult 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.
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 (1012 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 rm 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 mothers skin
Cover the infants 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 infants 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.
infants response, the following nursing measures can be
taken:
Administer warm, humid oxygen with face mask.
If no improvement, administer oxygen with bag and
mask.
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 clients 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 clients 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 clients 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 clients 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 clients feet. increases breathing difculties.
Use successful resolution of a problematic breathing episode as Promotes the clients 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 signicant 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)
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 clients
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 hyperination 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
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 aring
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 uid
balance
or narcotic overdoses
Stress management
Adequate hydration
Progressive ambulation
Pain relief
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
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?
No Finished
Copyright 2002 F.A. Davis Company
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 decit; 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 lling
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 ow 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 uid 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
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 uid 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 signicant others. If presence of signicant
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 signicant 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, uids, 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 specied for size of the infant or
child
Excessive bleeding. If in postoperative status, notify physician
if more than 50 mL/h or as specied.
Tolerance of feedings
Notify physician for:
(1) Premature ventricular contractions (PVCs) or other
arrhythmias
(2) Limits of pulse, respiratory rate, output criteria as
specied 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
specied 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
Womens 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 individuals 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 tness Assists in increasing cardiovascular tness during pregnancy.
during pregnancy. Some good exercises are:
Swimming
Walking
(continued)
Copyright 2002 F.A. Davis Company
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
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 Fergusons reex.
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
68 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 mothers efforts in pushing, and validate the
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor risk factors: Early identication 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 28 h) the clients cardiac functioning (list times
to observe here):
Vital signs
Chest sounds
(continued)
Copyright 2002 F.A. Davis Company
Mental status
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
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 signicant 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
program is initiated.66)
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
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.
Finished
CLASS 2ACTIVITY/EXERCISE
THE CORRECT DIAGNOSIS?
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 patients 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 uid balance on daily basis. Provides uid and nutrient necessary for activity.
(continued)
Copyright 2002 F.A. Davis Company
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 childs potential. as related to what daily living for the child involves.
Assist the family in identication of factors that will facilitate Identies 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 childs 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 1520 min each learning about condition.
nursing shift for this activity.
Assist the family in identication of support system for best Promotes coordination of care and cost-effective use of already
possible follow-up care. available resources.
Womens 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 reect 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 clients 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 clients perceived control and self-esteem.
protecting the client and others.
Obtain necessary medical orders to initiate methods that limit Provides protection of the clients rights. This should be done in
the clients physical mobility. congruence with the states legal requirements.
Carefully explain to the client, in brief, concise language, reasons High levels of anxiety interfere with the clients 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. clients perceived control.
Attempt to gain the clients 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
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 clients 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 specic and listed here. See Risk for
Violence, Chap. 9, for detailed information on behavior change
and contracting specics.)
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
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 tted 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 exibility 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 uids
Stress management
Pain relief
Prevention of hazards of immobility (e.g., antiembolism
stockings, ROM exercises, position changes)
Economic concerns
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
Repeat initial assessment. Does the client exhibit any signs or symptoms
of disuse syndrome?
Yes No
Finished
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 decit 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
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 signicant 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the patients 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 decits
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 childs interests, thus
diversional activity plan. increasing the likelihood of the childs participation.
Allow for peer interaction when appropriate through diversional Involvement of peers serves to foster self-esteem and meets
activity. developmental socialization needs.
Womens 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 signicant 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 decit.
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
(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 xing 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 decient diversional activity. Is the nursing unit Recognizes the impact of physical space on the clients mood.
appropriately stimulating for the level or type of clients, or is the
problem the clients perceptions?
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 1015 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 decient 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
Yes No
Has the patient implemented the plan? No Reassess using initial assessment factors.
Yes
No Finished
Copyright 2002 F.A. Davis Company
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 oximetershould be equal to or
more than 94).
Determine positive end-expiratory pressure (PEEP). Physiologic PEEP should be sufcient 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 sufcient 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 ow
associated with congenital decits
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 Specic 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 46 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
mechanical support
Womens Health
The nursing actions for Womens 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the patient for presence of factors that make weaning These factors can signicantly contribute to a delay in the weaning
difcult, 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
Response (DVWR)
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?
No Finished
Copyright 2002 F.A. Davis Company
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.
oor.
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. Identies 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 specic 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.
Womens Health
The nursing interventions for this diagnosis in Womens Health are the same as those for Adult Health
and Gerontic Health.
Copyright 2002 F.A. Davis Company
Psychiatric Health
The nursing interventions for this diagnosis in Psychiatric Health are the same as those for Adult 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-specic 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 decits can affect balance.13
properly functioning.
Consult with occupational therapist and phhysical therapist for The factors listed have been identied 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 oor surfaces
Raised thresholds
Slick oors
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 tting 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 tting, nonskid footwear
Utilize night lights in dark areas.
Reduce or eliminate clutter in trafc 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
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.
Finished
FATIGUE 289
4. Physiologic
Fatigue 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 4ACTIVITY/REST; g. Anemia
CLASS 3ENERGY BALANCE
RELATED CLINICAL CONCERNS
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC;
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 patients food and uid 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
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 signicant 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
childs and the familys perception of fatigue. progress will aid in a sense of mastery and objectify concerns.
Ensure safety needs according to the childs or infants age and Standard accountability is to provide for safety needs with special
developmental capacity. attention to the childs age, developmental capacity, parental
Womens 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 510 min with
feet propped above the abdomen.
During lunch, leave work area to rest 1015 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 68 h of sleep during night. (See Disturbed
Sleep Pattern, Chap. 6, for nursing actions to promote sleep.)
Involve signicant 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
Plan return to work on a gradual basis (e.g., work part-time for Provides gradual return to activities, and decreases likelihood of
the rst 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 clients
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 clients 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 clients control by providing increased opportunity
performance of tasks in energy-efcient 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 clients 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 tness, 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 clients 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
Clients perception of the problem reinforcement through social interaction with the nurse and verbal
Identication of thoughts that support the feeling of fatigue feedback about accomplishments.
Identication of thoughts that decrease feelings of fatigue
Identication of unrealistic goals
Clients evaluation of and attitudes toward self
(continued)
Copyright 2002 F.A. Davis Company
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 patients sleep pattern, Environmental noises and inattention to the patients 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 patients 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 sufcient pain control (analgesics, imagery,
meditation, etc.).
homemaker or meals-on-wheels).
FATIGUE 293
Fatigue
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?
No Finished
Copyright 2002 F.A. Davis Company
9. Confusion
Gas Exchange, Impaired 10. Dyspnea
DEFINITION 11. Abnormal arterial blood gases
12. Cyanosis (in neonate only)
Excess or decit 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 3ELIMINATION; 16. Headache upon awakening
CLASS 4PULMONARY SYSTEM 17. Abnormal rate, rhythm, and depth of breathing
18. Diaphoresis
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX; 19. Abnormal arterial pH
CLASS KRESPIRATORY MANAGEMENT 20. Nasal aring
NOC: DOMAIN IIPHYSIOLOGIC HEALTH;
CLASS ECARDIOPULMONARY 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
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor and document: Baseline factors that will allow assessment of the patients 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
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
Debrillation 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 childs
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 1015 min per shift for the family to verbalize Assists in reducing anxiety, and provides teaching opportunity.
concerns regarding the childs 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
specic situation. growth. Provides moral support to both siblings.
Copyright 2002 F.A. Davis Company
Womens 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 tness, and therefore increases oxygenation
pregnancy. and nutrition to placenta and fetus.
Teach the patient and signicant 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:
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 inuenza.
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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Ensure that oxygen delivery system is properly functioning and Basic care standards.
ts 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 ow and amount every 4 h around the clock at The patient may increase the liter ow 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, ushing, 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
clients 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
pneumonia immunizations
safety factors)
Stress management
ventilator, etc.)
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 difculty 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
Yes No
Are patients vital signs within normal limits? No Reassess using initial assessment factors.
Yes
No Finished
Copyright 2002 F.A. Davis Company
GROWTH AND DEVELOPMENT, DELAYED; DISPROPORTIONATE GROWTH, RISK FOR; DELAYED DEVELOPMENT, RISK FOR 301
C. Risk for Delayed Development
Growth and Development, Delayed; 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 ne motor skills. d. Positive drug screening test
e. Brain damage (e.g., hemorrhage in postnatal period,
NANDA TAXONOMY: DOMAIN 13GROWTH/ shaken baby, abuse, accident)
DEVELOPMENT; CLASS 1GROWTH AND f. Vision impairment
CLASS 2DEVELOPMENT g. Hearing impairment or frequent otitis media
NIC: DOMAIN 5FAMILY; CLASS Z h. Chronic illness
CHILDREARING CARE i. Technology-dependent
j. Failure to thrive
NOC: DOMAIN IFUNCTIONAL HEALTH; k. Inadequate nutrition
CLASS BGROWTH 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 difculty 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 signicant others
a. Infection 4. Environmental and stimulation deciencies
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. Decient 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
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 decit
or a subdecit 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 nd 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 Decient 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 condence 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 childs 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 difcult to get
brain damage or residual of brain damage. an accurate assessment of cognitive capability. The general health of
the patient will often inuence, 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 reects 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 childs
development, including identication 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.
Womens 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 rst 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 signicant 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 specic times] to discuss current concerns and feelings. feelings can facilitate identication and resolutions of problematic
coping behaviors.
Provide the client with familiar or needed objects. These should Promotes the clients 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 clients 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
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 specically and could cope with stressors.
Meet with the client and support system to provide information Enhances opportunities for success of the treatment plan.
on the clients situation and to develop a plan that will involve
the support system in making changes that will facilitate the
clients 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 reect 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 dened for Promotes discussion of the older adults 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 24 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 nger 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 decit)
Proper use of assistive equipment
Adapting to need for assistance or assistive equipment
Determining criteria for monitoring the clients 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
assistance
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
Medication organizers
Magnifying glass
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
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?
No Finished
Copyright 2002 F.A. Davis Company
2. Subjective
Home Maintenance, Impaired a. Household members express difculty in maintaining their
DEFINITION home in a comfortable fashion.
b. Household members describe outstanding debts or nancial
Inability to independently maintain a safe growth-promoting crises.
immediate environment.21 c. Household members request assistance with home mainte-
nance.
NANDA TAXONOMY: DOMAIN 1HEALTH
PROMOTION; CLASS 2HEALTH MANAGEMENT RELATED FACTORS21
NIC: DOMAIN 5FAMILY; CLASS XLIFE SPAN 1. Individual or family member disease or injury
CARE 2. Unfamiliarity with neighborhood resources
3. Lack of role modeling
NOC: DOMAIN VIFAMILY HEALTH; CLASS X 4. Lack of knowledge
FAMILY WELL-BEING 5. Insufcient family organization or planning
6. Impaired cognitive or emotional functioning
DEFINING CHARACTERISTICS21 7. Inadequate support systems
8. Insufcient nances
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 Alzheimers 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 immunodeciency syndrome (AIDS)
h. Lack of necessary equipment or aids
i. Offensive odors
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 specic 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 childs illness or
hospitalization
Hygienic practices
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 identied needs reduces anxiety and promotes
situation, e.g., seeming inability to manage with overwhelming self-condence in ability to manage.
demands of the childs need for care, such as a premature infant
or a child with cerebral palsy who has feeding difculties.
Provide 1015 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.
Womens 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
to be made.
does not always have to get up for the infant. Or the mother
Cook several meals at one time for the family and freeze them
later use.
signicant other can then feed the infant one time at night so
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the client his or her concerns about returning home. Promotes the clients sense of control, which enhances self-esteem.
Develop with the client and signicant others a list of potential Promotes the clients and support systems 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 nancial difculties prevent home maintenance, refer to social
services or a nancial 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 specically 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
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 specied tasks as appropriate to reduce
the Impaired Home Maintenance (shopping, washing clothes,
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
walkways
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?
No Finished
Copyright 2002 F.A. Davis Company
INFANT BEHAVIOR, DISORGANIZED, RISK FOR AND ACTUAL, AND READINESS FOR ENHANCED ORGANIZED 313
C. Readiness for Enhanced Organized Infant Behavior
Infant Behavior, Disorganized, Risk for 1. Denite 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
Risk for Disorganized Infant Behavior Risk for alteration and RELATED FACTORS21
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
b. Immature neurologic system
NANDA TAXONOMY: DOMAIN 9COPING/STRESS c. Gestational age
TOLERANCE; CLASS 3NEUROBEHAVIORAL STRESS d. Postconceptual age
NIC: DOMAIN 5FAMILY; CLASS Z 4. Environmental
CHILDREARING CARE a. Physical environment inappropriateness
b. Sensory overstimulation
NOC: DOMAIN IFUNCTIONAL HEALTH; c. Sensory deprivation
CLASS BGROWTH AND DEVELOPMENT 5. Caregiver
a. Cue misreading
DEFINING CHARACTERISTICS21 b. Cue knowledge decit
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., difcult 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, sting, 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 reexes 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 ushed 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 infants 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
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
infants 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 mothers and fathers (parental) perception of the Ultimate responsibility will better be assumed by the caregiver if
infants status. planning is long term and considers parental input.
Identify specic parameters (according to etiologic or known Treatment of condition will be enhanced with a specic,
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 infants care;
i.e., when to call for assistance
Risk factor analysis of total 24-h care of the infant
Ability to identify the infants cues
Ability to respond to the infants cues
Ability to handle, emotionally and otherwise, demands of the
infants 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
infants 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
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
ACTIONS/INTERVENTIONS RATIONALES
Monitor the infants cardiovascular and respiratory system by Apgar score is an indicator of the infants 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 infants 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 clarication 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 rst 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 infants physiologic parameters Utilizing every opportunity to teach new parents about their
during periods of reactivity: newborn increases condence 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 ndings in an organized manner (usually head
to toe).
(continued)
Copyright 2002 F.A. Davis Company
preventing infection.
of the infant.
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. (Infants 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 infants 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 mothers 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 infants 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
The practitioner should review the denition and dening characteristics of these diagnoses to determine
which one relates to those characteristics being demonstrated by the infants 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
Enhanced Organized
Yes No
Record data, e.g., TPR and BP within Reassess using initial assessment factors.
normal limits, sleeps 46 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?
No Finished
Copyright 2002 F.A. Davis Company
3. Thrombophlebitis
Peripheral Neurovascular Dysfunction, 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 11SAFETY/ Ineffective Tissue Perfusion Ineffective Tissue
PROTECTION; CLASS 2PHYSICAL INJURY Perfusion is an actual diagnosis and indicates
that a denite problem has developed. Risk
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC;
for Peripheral Neurovascular Dysfunction
CLASS AACTIVITY AND EXERCISE MANAGEMENT
indicates that the patient is in danger of
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; developing a problem if appropriate nursing
CLASS ECARDIOPULMONARY 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.
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 uid 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 patients 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Determine exact parameters to be used in monitoring risk Specic parameters for assessment of neurodecits can guide
concerns, e.g., if the patient is without sensation in specic caregivers in choosing the best precautionary treatment.
levels of anatomy, document what the known decits are: High
level of myelomeningocele, lumbar 4, with apparent sensation
in peroneal site.
Carry out treatments with attention to the neurologic decits, 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 childs 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.
Womens 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 days 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.
teaching opportunity.
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
Risk for
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Maintain proper body alignment at all times; support extremities Prevents exion contractures.
with pillows, blankets, towel rolls, or sandbags. Use footboards,
rm 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 specic 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 signicant 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
Womens 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 signicant 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
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
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 clients 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.
following interventions:
(1) Sit with the client for [number] minutes [number] times
(2) Establish clear expectations for these interactions, e.g., Communicates respect for the client, and facilitates the clients
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 clients 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 signicant others enhances self-esteem.
Recognize the clients perceptions about the difculty 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 nds 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 nds
rewarding: (1) time with nurse and (2) coffee.
Have the client identify perceived barriers to increased physical Promotes the clients sense of control, and increases the clients
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 clients 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
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
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 decit
Musculoskeletal decit
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 oor,
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
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
NOTE: Self-care decits range from a total self-care decit to very specic areas of self-care decits,
such as bathing-hygiene or feeding. The nursing actions presented are general in nature and would
need to be adapted to t the exact self-care decit of the individual. Collaboration with a rehabilita-
tion nurse clinician and/or review of rehabilitation literature would be excellent sources for current
and specic nursing actions related to a patients particular self-care decit. 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 signicant others in planning measures to Promotes timely home care planning and encourages participation
overcome or adapt to self-care decits: 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the patients 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 childs 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 familys
repetition, or reluctance. needs.
Provide opportunities that will enhance the childs condence Condence in self-care will enhance self-esteem.
in performing self-care.
Womens 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 signicant other take care of the housework and other
children.
Learn to sleep when the baby sleeps.
Have specic, set times for friends or relatives to visit.
(continued)
Copyright 2002 F.A. Davis Company
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
rst weeks.
Cord care
(1) Clean cord with alcohol and cotton swabs when
changing diapers.
Clothing
Diapering
(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 710 days).
(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.
(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 clients 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
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 decit. or changes in lifestyle.87
Contract with the patient for achievement of specic Enhances motivation to increase self-care.
incremental goals, and provide rewards or reinforcements
when goals are met.
Copyright 2002 F.A. Davis Company
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor factors contributing to self-care decit 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 specic self-care decit:
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 clients 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
Dressing-Grooming, Toileting)
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?
No Finished
Copyright 2002 F.A. Davis Company
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 patients 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
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Determine parameters for respiratory status: A specic 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: 3060
(2) Infants: 2560
(3) Toddlers: 2440
(4) Preschoolers: 2234
(5) Adolescents: 1216
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. Identication 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
Womens Health
The nursing actions for Womens 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
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?
No Finished
Copyright 2002 F.A. Davis Company
TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 341
j. Bruits
Tissue Perfusion, Ineffective (Specify Type: 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
A decrease in oxygen resulting in failure to nourish the tissues at
RELATED FACTORS21
the capillary level.21 1. Hypovolemia
2. Interruption of arterial ow
NANDA TAXONOMY: DOMAIN 4ACTIVITY/REST; 3. Hypervolemia
CLASS 4CARDIOVASCULAR/PULMONARY 4. Interruption of venous ow
RESPONSE 5. Mechanical reduction of venous and/or arterial blood ow
6. Hypoventilation
NIC: DOMAIN 2PHYSIOLOGICAL: COMPLEX; 7. Impaired transport of oxygen across alveolar and/or capillary
CLASS NTISSUE PERFUSION MANAGEMENT membrane
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; 8. Mismatch of ventilation with blood ow
CLASS ECARDIOPULMONARY 9. Decreased hemoglobin concentration in blood
10. Enzyme poisoning
11. Altered afnity 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. Difculty in swallowing 9. Kawasakis 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 rell 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 decits in the
h. Dyspnea
peripheral circulation with cellular impact.
i. Arrhythmias
Decreased Cardiac Output relates
j. Nasal aring
specically 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
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 uid ow. 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
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 rell
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 uid 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 modies sympathetic nervous system
per shift while awake at [times]: response.
Stress management techniques
Relaxation techniques
Teach the patient and signicant 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
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 uids
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
Womens Health
NOTE: In instances of decreased coronary tissue perfusion, the womens 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 tness 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
Oliguria
Hyperreexia
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.
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 hyperreexia, especially transient or sustained ankle
clonus
Severe headache
Visual disturbances
Epigastric pain
Increase in proteinuria
Drowsiness
In collaboration with dietitian: Dietary measures that assist in controlling blood pressure.
Obtain nutritional history.
Provide high-protein diet (80100 g of protein).
Provide low-sodium diet (not more than 6 g daily or less
than 2.5 g daily).
disease
Psychiatric Health
NOTE: The nursing actions in this section reect 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 clients mental status. If compromised, provide
information in a clear, concise manner.
Discuss with the client causes of decreased cerebral blood ow. 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 oor 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 clients
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 ow, 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 clients uid 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 ow, 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 t 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 signicant others to assist with foot care of elderly
client
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 3045 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 clients exercise by:
Walking with him or her
Determining things that the client would nd rewarding and
supplying these as goals are achieved
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 insufciency. with these symptoms.
(continued)
Copyright 2002 F.A. Davis Company
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 uctuations
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
foot cradle)
TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE: RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) 349
Gastrointestinal, Peripheral)
Yes No
Reassess using initial assessment factors. Record data, e.g., carotid and temporal
pulses easily palpatedstrong 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.
Finished
CLASS 2ACTIVITY/EXERCISE
RELATED FACTORS21
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC;
To be developed.
CLASS AACTIVITY AND EXERCISE MANAGEMENT
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.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
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 learners needs will most likely ease anxiety
caregivers how to assist in transfer activities. and afford consistency in safe manner.
Determine a reward system to t 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 patients status Principles of safety may be altered yet upheld for changes that
and futuristic needs of change of environment. occur.
Allow sufcient 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 satised.
Womens Health
The nursing actions for Womens 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
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
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?
No Finished
Copyright 2002 F.A. Davis Company
4. Neuromuscular disorders
Walking, Impaired 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 4ACTIVITY/REST;
CLASS 2ACTIVITY/EXERCISE
Impaired Physical Mobility Impaired walking
could be considered to be a subset of Impaired
NIC: DOMAIN 1PHYSIOLOGICAL: BASIC;
Physical Mobility and is a more specic
CLASS AACTIVITY AND EXERCISE MANAGEMENT
diagnosis. If the patient is having difculty only
with walking and not other aspects of mobility,
NOC: DOMAIN IFUNCTIONAL HEALTH;
such as moving in bed and getting up and
CLASS CMOBILITY
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
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Collaborate with Physical Therapy as needed. To assist in planning the ambulation activities.
Review the patients 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 t 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 patients 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
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 Specic 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 patients 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.
patients developmental capacity.
Assess the patients 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
Womens Health
The nursing actions for Womens 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) ts 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 clients ambulatory ability.
Encourage client participation in a walking program, if available Promotes the clients 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 tting shoes, shiny oor
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.
Ensuring that all assistive devices are set to the correct height.
Walking, Impaired
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?
No Finished
Copyright 2002 F.A. Davis Company
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 Alzheimers 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 denition and dening characteristics, would not be appropriate for Child
Health.
Womens Health
Interventions for a Womens 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 identication 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, re risks, or rearms).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.
Alzheimers Association Safe Return Program.
Ensure that there is an updated client photograph available. Assists in identication efforts. As dementia progresses, there may
be marked changes in the clients 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 clients activity and
early afternoon or after evening meals.98 exercise needs.
Based on client preference, use music for 2030 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 (1020 min) Slow-stroke massage has been helpful with some dementia clients
to the clients 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 clients Familiar objects may provide a sense of comfort for the client.
surroundings.
Use distractions such as preferred activities, food, or uids 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
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Consult with and/or refer the patient to assistive resources such Utilization of existing services is an efcient 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
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?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Collaborate with Physical Therapy as needed. To assist in planning activities to improve the patients 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.
Dene limitations of tolerance for positioning, movement, and Critical thresholds will assist in dening reasonable likelihood for
ideal plan for mobility. success.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
The nursing actions for Womens 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 t for the client (adequate seat Proper t enhances the clients 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
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?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 6
Sleep-Rest Pattern
spinal cord, and cerebral cortex and the bulbar synchronizing portion
Pattern Description 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 specically 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 patients 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 difcult arousal. Stage 4
restores and allows the body to rest. These stages are known as
Pattern Assessment nonrapid 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 persons 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-
quire the most sleep. As the nurse assesses the patients needs for
Conceptual Information 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 inuence of disease process on
necessarily afford rest. Rest is a reduction in bodily work that re- sleep-rest patterns.
sults in the persons 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
sons energy and sense of well-being. brief form of narcolepsy, is an abrupt and reversible decrease or loss
Studies have conrmed 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 inuence 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
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 Ondines 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 wakefulnessand, within it,
show marked obesity and associated alveolar hypoventilation, sleep the basic rest-activity cycleshow 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 Ondines 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- rst 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 inuence a persons 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 clients achievement of essential rest and sleep. and pertussis; viral infections such as respiratory syncytial virus;
metabolic abnormalities; administration of sedatives; seizures; and
chronic hypoxia. If these causes are ruled out, the infant is diag-
Developmental Considerations 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 cycleactive (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 identication, hypopnea, pro-
explain why the older patient wakens more easily and spends time longed expiration, apnea and reux, 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 infants 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 identication 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 rst 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 parents 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
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
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 signicant 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
identied to be barriers to sleep.
Determine teaching needs of the client, parents, or caregivers. Specic knowledge regarding sleeping and waking cycles facilitates
individualized match of needs for clients and caregivers.
Reevaluate measures to dene 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 identication 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 sufcient 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 clients
condition and needs.
Monitor for mental and cognitive capacity, with attention to Identication of related onset of interference in usual mental or
subjective or behavioral changes. behavioral domain will help minimize greater disturbance of the
clients 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
Womens Health
Nursing actions for the Womens 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.1719
Assess the clients 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 difcult to begin sleep. Irregular daily cycles can interfere with
sleep patterns. Also the clients 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 clients
current stressors. ability to relax sufciently to sleep normally.18
Spend 30 min each shift in the rst 24 h to review with the client Understanding the clients 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 clients 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 clients Routine promotes relaxation.19
routine here.
Provide a light, high-carbohydrate snack before bedtime. Note Hunger can interfere with normal sleep patterns. Carbohydrates
the clients 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
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
Sleep Deprivation
FLOWCHART EVALUATION: EXPECTED OUTCOME
Review chart for past 48 hours. Audit hours of sleep. Is the patient
sleeping uninterrupted for at least 68 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.
Patients comments validate amount of
uninterrupted sleep. Record RESOLVED.
Delete nursing diagnosis, expected
outcome, target date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
ff. Fatigue
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
uids, 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 uids after 6 p.m.; limit uids Warm drinks are relaxing. Limiting uid 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 6872F. 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 patients usual Follows the patients established pattern; promotes comfort; and
bedtime routine. allows the patient to wind down.
Close door to room; limit trafc 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 patients comfort, and follows the patients 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.
patients 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
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 1530 min before scheduled sleep timeformula, snack In young infants and small children, a sense of fullness and satiety,
of protein and simple carbohydrate, no fats. without difculty in digestion, promotes sleep without the
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
Provide environment conducive to sleeproom temperature of Lack of unpleasant stimuli will provide sensory rest, as well as a
7478F, soft, relaxing music, or night light. chance to tune out need for cognitive-perceptual activity.
Restrict loud physical activity at least 23 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 nurses 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 dening 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 condence 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 childs 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-tting sheets; and bedrails to prevent falling out
of bed.
Womens 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 infants 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, uids, or
activity
(continued)
Copyright 2002 F.A. Davis Company
Collaborate with the womans 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 clients 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 clients self-esteem.
accomplishments. (Note: This is for clients with increased activity.)
Go to the clients 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. individuals 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
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).
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
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?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 7
Cognitive-Perceptual Pattern
381
Copyright 2002 F.A. Davis Company
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 Piagets
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 conict 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 persons 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, uid balance, and sensual stimulation
Cognition is the process of obtaining and using knowledge about
ones 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-
The full-term newborn has several sensory capacities. The neonate
dictable sensory input.
should have a pupillary reex in response to light and a corneal re-
There are two general approaches to contemporary cognitive the-
ex in response to touch. The sensory myelination is best devel-
ory. The information-processing approach attempts to understand
oped at birth for hearing, taste, and smell.
human thought and reasoning processes by comparing the mind
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 xate on a
or designs. bright or moving object held within 8 inches and in the midline of the
Copyright 2002 F.A. Davis Company
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
ets 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 inuenced greatly by mandatory that caution be exercised in assessing for decits 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. Difculties 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 decit 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 inuenced by the familys 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 ne 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-
By now the adolescent is capable of formal operational thought
sistance to parental authority is common, and the child is still ego-
and is able to move beyond the world of concrete reality to abstract
centric in thought. This makes it difcult to apply universal under-
possibilities and ideas. Problem solving is evident with inductive
standing of use of language and symbols for children of this age, for
and deductive capacity. There is an interest in values, with a ten-
example, death may be perceived as sleep.
dency toward idealism. Attention must be given to the adolescents
By this age, there should be a general notion of the cognitive ca-
sensitivity to others and potential for rejection if body image is al-
pacity for the child. The child explores the world in a meaningful
tered. Of particular importance at this time are sports and peer-
fashion and still relies closely on primary caregivers. If there are
related activities. As feelings are explored more cautiously, there is
marked delays, they should be monitored with a focus on main-
a tendency to draw into oneself at this stage. There may be major
taining optimum functioning with developmental sequencing.
conicts over independence when self-care is not possible.
The preschooler will enjoy activity and is beginning to enjoy
The adolescent fears mutilation and attempts to deal with pain as
learning colors, using words in sentences, and gradually forming
an adult might. Self-control is strived for, with allowance for capi-
relationships with persons outside the immediate family. If there
talization on gains from pain. Sexuality factors of role performance
are delays, they should continue to be monitored. By now, major
enter into this group as pain occurs. As with the adult, an attempt
decits in cognition become more obvious.
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 signicant 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 componentthe cause or source of pain, as well in acuity and accommodation after approximately 40 years of age.
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Hyperventilate as necessary. Decreased PaCO2 leads to vasoconstriction and thus reduces
cerebral blood ow.3
Monitor arterial blood bases (ABGs). Maintain PaO2 80 mm Hyperventilation produces systemic alkalosis, which passes
Hg; PaCO2 at 2533 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 ow 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 uid (CSF).4,5
Monitor CSF for lactate and creatinine kinase BB bands. Reects 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 030 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 at.10
hyperextend head and neck. Do not turn head to right or left or
place head and neck in a exed position.8 Avoid hip exion of
more than 90 degrees.
Turn every 2 h. Have sufcient 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 ghting 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 12 hour before neuroassessment. Cover period
with morphine.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
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 infants or expedite treatment plan.
childs status.
Maintain head of bed 30 degrees, with head in line with Neutral body alignment will assist in stabilizing the intracranial
bodyideally not positioned from side to side unless specied. 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 infants or childs likelihood of rest
according to the infants or childs 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 infants or childs status. concerns.
Provide adequate teaching regarding equipment, procedures, Knowledge allows for acceptance and understanding of the infants
surgery, etc. or childs 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 infants or childs condition. abreast of activities on ongoing basis.
Encourage the parents to bring the infants or childs 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.
Womens Health
For Womens 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.
(continued)
Copyright 2002 F.A. Davis Company
NEWBORN
Carefully assess the newborn for cranial injury.
Carefully examine the infants 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 exion 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, decits 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
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?
No Finished
Copyright 2002 F.A. Davis Company
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
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 identication and
applicable: treatment of confusion.
Prenatal inuences, 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
infants or childs status. likelihood of sense of security for all.
Identify current plan of care to best suit the infants or childs Best holistic plan of care reects 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
CHRONIC
Offer resources for support groups and advocacy interest Specic support groups will assist the parents in dealing with
opportunities. situation represented by the infants or childs status.
Explore specic 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.
Womens 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, disulram, 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, specic 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.3234
Place identifying information on the patient and the patients Promotes safety and orientation.
room. Utilize the patients 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 indenite pronouns. preserves self-esteem, decreases anxiety, and improves
orientation.35
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
CHRONIC
NOTE: Mental health clients at risk for this diagnosis include those
with Alzheimers disease, Korsakoffs 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 decits 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 clients 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 clients needs, perspective, and treatment plan.
Excessive stimulation can exacerbate cognitive or behavioral problems.
Provide structured daily routines, and note the clients 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 clients group
schedule here, with the assistance needed from nursing staff.
Spend [number] min [number] times a day discussing the Promotes positive reorientation, maintains the clients dignity, and
clients 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 difculty coping with past
Note the clients 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 clients dignity and sense of control.39 Each of these
cognitive and behavioral problems. This could include limiting factors can decrease the clients 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 clients dignity, and recognizes the limitations of
extremes. This could include changing the clients 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 clients 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 clients 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
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 difcult 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
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?
Finished
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?
No Finished
Copyright 2002 F.A. Davis Company
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 specic 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 patients 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, nd, 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
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 childs care. It is
likewise essential for all caregivers to know who the legal guardian
or spokesperson is.
In instances of conicting decision makers, ensure that the Irrespective of conicts in decision making, the infant or child is
childs rights are protected according to legal statutes. entitled to appropriate care. In extreme cases of conict, 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.
conict.
Consider potential long-term residual or subsequent effects Decision making often has far-reaching effects, e.g., in early
related to specic decisional conict 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.
Womens 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 condentiality.
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 signicant 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 patients 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 signicant other their views on
children and family.
Copyright 2002 F.A. Davis Company
Womens Health
Less-Than-Perfect Infant
NOTE: Families faced with the birth of a child with congenital anomalies or developmental defects ex-
perience decisional conict 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 mothers 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 signicant 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 conict.
care when leaving hospital.47,48
Psychiatric Health
NOTE: The client who is experiencing a decisional conict is faced with confusion about alternative
solutions. When assisting these clients, the nurse should be careful not to connote the clients confu-
sion negatively. Various authors4951 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 difculty 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 difculty, 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 clients 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 clients 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the patient prior examples of Decisional Conict 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 clarication between the client
Conict: and family will reduce conict.
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
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.
No Finished
Copyright 2002 F.A. Davis Company
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 clients
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 patients anxiety and reinforce intensity delusions.53
If the patient becomes aggressive, focus on underlying feelings Focusing on feelings increases the patients 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. patients sense of competency and self-esteem.
Keep the patients room well lighted. Maintain a calm Decreases possibility of environmental sensory misrepresentations,
environment. and helps meet patient safety needs.
Teach the family about the patients condition and how to Assists the family in understanding changes in the patients
interact more effectively with the patient; i.e., provide ongoing orientation, cognition, and behavior. Increases the familys sense of
orientation to surroundings and happenings within the family. competency in relating to the patient.
Refer to psychiatricmental health CNS. Make other referrals to The psychiatric-mental health CNS has the expertise to collaborate
community agencies as needed, i.e., Alzheimers 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
Child Health
This diagnosis may present in children also; if so, the same basic plan of care as that of adults should be
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 specic Offers reduction in anxiety, plus an opportunity to note parental
concerns regarding the infant or child. concerns.
Womens 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 clients 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 decits.
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., specic 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 patients Provides safety and promotes orientation.
room. Utilize the clients 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 clients
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 specic interventions.
Provide daily routine that closely resembles the clients normal Promotes orientation, and increases the clients 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 clients 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 clients 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 clients make choices may have negative impact on the clients 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 clients 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 clients 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Review mental status examination to identify areas of strengths Depending on examination used, may indicate the clients 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 specic areas or Assists the client to interpret environment.
conveniences (such as universal symbols for food or restrooms
or pictures to indicate the clients room).
Ensure identication of the client (ID bracelet or necklace). Provides means of identication 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 identication 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
Impaired
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?
No Finished
Copyright 2002 F.A. Davis Company
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 decit; allows assessment of the
Have the patient sign contract to ensure patient consent for patients readiness to learn. Improves learning because it is based
teaching. Review the patients and familys 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 specic to the patients decit area, e.g., Provides new knowledge based on the patients perceived needs.
self-administration of medication, and specic to the patients 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
signicant others in teaching sessions. Be sure plan includes learning.
content, objectives, methods, and evaluation.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Determine whether there are ambiguities in the minds of the Clarication and verication 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 alldo 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
Womens 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 ow
(1) Normal: Rubra 13 days; serosa 310 days; alba
1014 days
(2) Abnormal: Bright red blood and clots with rm 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-tting 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 clarication 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 signicant 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
signicant 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 newborns
capabilitiesgestational 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 condence when caring for the newborn.
Provides opportunity for nurse to teach and reinforce teaching.
(continued)
Copyright 2002 F.A. Davis Company
Discuss signs and symptoms of perimenopausal and menopausal Clients who are informed and active participants in their own
changes with the woman: hot ashes, 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).5456
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Ask the client about previous learning experiences in general Helps determine aspects of the clients 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 clients 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. clients 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 clients 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 Maslows 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 clients perceptions of need. When information is presented when
appropriate to the clients 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
information provided.
Provide positive verbal reinforcement for the clients 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 signicant 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 signicant 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
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 patients 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 individuals 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 individuals
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 decit 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 learners 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 decit. Provides the
decit 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,
familiar surroundings)
self-care management
Yes No
No Finished
Copyright 2002 F.A. Davis Company
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 patients efforts to remember bits of Reinforcing the patients 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 conrmed underlying medical diagnosis. should improve as the condition becomes resolved. Memory
generally will not improve and will likely deteriorate over time.
Teach the family about the patients condition and how to Assists the family in understanding underlying cause(s) for memory
respond to the patients loss of memory. impairment. Increases the familys sense of competency in relating to
the patient during periods of memory loss.
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 childs interests when the
the parents are unable to offer this component. parents cannot.
Womens Health
Same as Adult Health except for magnesium sulfate therapy specic to pregnancy-induced hypertension.
For midlife women, the actions and interventions are the same as those given for perimenopausal and
menopausal life periods in Decient Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the clients level of anxiety, and refer to Anxiety Anxiety can increase the clients 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 clients confusion and
disorganization, increasing memory problems.
Interact with the client for [number] minutes every 30 min. Time of interaction should be guided by the clients 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
clients safety needs.
Initially, place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to the clients
sense of disorganization and confusion, increasing memory
problems.
Orient the client to the environment, and assign someone to Promotes the clients 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 nished 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 reection 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 clients specic 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 specic techniques to be practiced. clients 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Introduce self with each client contact. Promotes comfort for the client to identify caregiver.
Use the clients preferred name in course of conversations. Provides orienting cue to the clients identity.
Request photographs and names of signicant 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 identication 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 Dont 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 uid 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
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
ability.
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 clients functional ability.
reminiscence and memory practice exercises.
Teach the client and family compensation strategies, e.g., daily Compensation strategies can increase the clients functional ability.
planner or checklists.
Copyright 2002 F.A. Davis Company
Memory, Impaired
FLOWCHART EVALUATION: EXPECTED OUTCOME
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.
Finished
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, xed 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
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 010 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 (010). 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 bers 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 23 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 patients 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 uid 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. uids 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 patients 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
Contralateral stimulation
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 signicant 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
Splinting
nursing action)
technique
measures
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 patients 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 modication of
required: planning.
Physical injury or surgical incision
Stressors
Fears
Knowledge decit
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 signicant others by: value and respect for the individuals 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
ventilation at [times]
chronic pain)
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 childs 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.
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.
Womens Health
Gynecologic Pain
NOTE: A signicant 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 difcult 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 womans 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 patients 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
Womens 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 signicant 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 patients 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
reex.
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 babys 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
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 nurses response to the clients perception of pain. If the The nurses response to the client can be communicated and have
nurse has difculty understanding or coping with the clients an effect on the clients 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 clients awareness of this pattern, and allows the nurse
of day, recent social interactions, or physical activity. If a pattern to assess the clients perception of this observation.
is present, begin a discussion of this observation with the client.
Determine effects pain has had on the clients life, including role Assesses meaning of pain to the clients amount of anxiety associated
responsibilities, nancial impact, cognitive and emotional with the pain and possible benets of pain in the clients life.
functioning, and family interactions.
Review the clients beliefs and attitudes about the role pain is If pain is assuming an important role, then it might be difcult for
assuming in the clients life. If pain is very important to the the client to give up all of the pain, and this should be considered
clients denition 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 clients pain is special and that it would
be difcult, 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-specic 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 difculty in discussing
these concerns. Refer to the self-esteem diagnoses (Chap. 8) for
specic 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 bosss 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 specic 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
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 clients 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 clients 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 difcult, 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 clients 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 nds 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 clients 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
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
ACUTE PAIN
Medicate every 46 h rather than on an as needed (PRN) basis Enhances pain control, and thus promotes early mobility, which
for the rst 4872 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 patients 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 wont 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 signicant 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-inammatories
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 signicant 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
Communication
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
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
Review prn medication record. Has the patient required more than
one analgesic in past 24 h?
Yes No
Finished
SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 431
7. Electrolyte imbalance
Sensory Perception, Disturbed (Specify: 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 5PERCEPTION/
COGNITION; CLASS 3SENSATION/PERCEPTION
NIC: DOMAIN 3BEHAVIORAL; CLASS Q HAVE YOU SELECTED
COMMUNICATION ENHANCEMENT THE CORRECT DIAGNOSIS?
NOC: DOMAIN IIPHYSIOLOGIC HEALTH; Disturbed Thought Process Disturbed
CLASS YSENSORY FUNCTION Thought Process refers to a patients
cognitive abilities, whereas Disturbed
DEFINING CHARACTERISTICS2 Sensory Perception relates to just the sensory
input-output.
1. Poor concentration Self-Care Decit Certainly sensory
2. Auditory distractions perception problems could result in self-care
3. Change in usual response to stimuli decits; 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 [specic sensory decit] by [date].
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Provide the patient with appropriate prosthesis if the decit has Provides immediate assistance with sensory decit to decrease
been previously diagnosed and prosthesis provided. decit.
Maintain prosthesis to ensure optimal functioning. Prosthesis that does not t 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 specic
decit
(continued)
Copyright 2002 F.A. Davis Company
VISUAL DEFICIT
Provide the patient with his or her eyeglasses or contact lenses Facilitates the patients 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 patients room with large numbers or the patients
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 patients Makes the patient aware of presence.
proximity, and approach the patient from the front.
Do not alter the patients physical environment without telling Promotes consistency in environment, which improves safety.
him or her of the changes.
Address the patient by name. Clearly identies 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 patients 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).
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 decit has on the patients 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 specic appointments lessens the confusion about the
specics of appointments and increases the likelihood of
subsequent follow-through.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Determine how the parent and child perceive the decit 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 decits is
sensory decits of infants and young children. enhanced by appropriate attention to sensory perception follow-up.
Allow for extra anticipatory safety needs according to sensory Sensory decits and developmental capacity increase the risk of
decit and the childs 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 condence in performance of necessary tasks feedback and corrective action. Lessens anxiety and performance
according to decit. pressures. Increases condence in giving care at home.
Provide attention to family coping as it may relate to the decit: A child with sensory perception problems and the interventions
Assessment of usual dynamics necessary to deal with these problems place strain on the family.
Identication of impact on the parents and siblings Promoting coping will lessen strain for the family while increasing
Presence of mental decits the likelihood that the childs needs will be met.
Values regarding the decit
Support systems
Review for appropriate immunization, especially rubella, In the event of early decits, 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
childs age and situation
Provide continuity in stafng 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.
Womens 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, hyperreexia, 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 patients 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 fetuss 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
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
KINESTHESIA
Be aware of the expectant mothers 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 reexes
Tires easily
Assist in and out of furniture that is too low and difcult 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 clients neurologic status as indicated by current Client safety is of primary importance. Early recognition and
condition and history of decit, e.g., if decit 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 ow
sheet.
If decit 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 decits 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 decit is related to a physiologic dysfunction, attend to needs Provides positive reinforcement for adaptive coping behaviors.
resulting from the identied sensory decit in a matter-of-fact
manner, providing basic care and having the client do the
majority of the care.
If decit is related to a psychological dysfunction, spend 15 min Promotes the clients sense of control, and increases self-esteem.
every hour with the client in an activity that is not related to the
sensory decit. If the client begins to focus on the decit,
terminate the interaction.
Spend 1 h twice a day discussing with the client the effects the
decit will have on his or her life and developing alternative
coping behavior. Note times for conversations here. If the family
is involved in the clients 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 decit
or if current emotional adaptation becomes complicated.
Discuss with the client and support system the necessary Promotes the clients 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
When the client is not constantly experiencing alterations, Facilitates interaction, self-management, and monitoring of
engage him or her in a group that addresses management of symptoms, and instills hope.70
these alterations.
When the client is responding to hallucinations, respond to the
feelings expressed in the clients communication.
Respond to the client with I statements (I do not see or hear Provides indirect confrontation of their experience. Preserves
that) when they request validation of hallucinations. Do not self-esteem while indicating that nurse does not experience the
argue with clients experience. same stimuli.71
Talk with the client about ways to distract himself or herself
from the hallucinations, such as physical exercise, playing a
game or a craft that takes a great deal of concentration. (Note
those activities preferred by the client here.)
When signs of the clients hallucinating are present, assist the Reinforces new coping behaviors, and increases the clients
client in initiating those activities or other control behaviors that perceived control.
have been identied by the client as useful.
As the clients condition improves, primary nurse will assist the Facilitates the development of alternative coping behaviors.
client to identify onset of hallucinations and situations that
facilitate their onset.
As difcult situations are identied, primary nurse can begin Promotes the clients sense of control and self-esteem.
working with the client on alternative ways of coping with these
situations. (Note alternative coping behaviors selected by the
client here.)
Refer the client and support system to appropriate support Establishes continuity of responses and support for the client after
systems in the community, e.g., Compeer. (Contact local mental discharge.
health association for programs in your community.)
Arrange time with signicant others to provide education about
sensory-perceptual alterations and appropriate responses to
them.
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health
patient.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family measures to prevent sensory decit: Family and client involvement in basic safety measures enhances
Use of protective gear, e.g., goggles, sunglasses, earplugs, or the effectiveness of preventive measures.
Involve the client and family in planning, implementing, and Involvement improves motivation. Communication and mutual
promoting correction or compensation for sensory decit goals increase the probability of positive outcomes.
[specify] by [date]:
Family conference
Mutual goal setting
Communication, e.g., use of memorabilia and audiotapes or
videotapes provided by family members to stimulate in cases
of impaired communication72
Assist the patient and family in lifestyle adjustments that may be Lifestyle changes require change in behavior. Self-evaluation and
required: support facilitate these changes.
Assistance with activities of daily living
Adjustment to and usage of assistive devices, e.g., hearing aid,
corrective lenses, or magnifying glass
Consult with or refer to appropriate assistive resources as Use of the network of existing community services provides for
indicated. effective utilization of resources.
Copyright 2002 F.A. Davis Company
SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 439
Tactile, Olfactory)
Yes No
Record data, e.g., use of large letters Reassess using initial assessment factors.
for labeling at home and appointment
made for new glasses; grandson is
making labels; has appointment with
ophthalmologist tomorrow. Record
RESOLVED (may want to use
CONTINUE until patient is discharged
from your service). Delete nursing No Is diagnosis validated?
diagnosis, expected outcome,
target date, and nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
7. Schizophrenic disorders
Thought Process, Disturbed 8. Dissociative disorders
DEFINITION 9. Obsessive-compulsive disorders
10. Paranoid disorder
A state in which an individual experiences a disruption in cognitive 11. Delirium
operations and activities.2 12. Eating disorders
RELATED CLINICAL CONCERNS Will have at least a [number] percent decrease in signs and symp-
toms of Disturbed Thought Process by [date].
1. Dementia
2. Neurologic diseases affecting the brain TARGET DATES
3. Head injuries
4. Medication overdose, for example, digitalis, sedatives, or narcotics A target date of 5 days would be acceptable because this can be a
5. Major depression very long-range problem.
6. Bipolar disorder, manic or depressive or mixed
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor at least every 4 h while awake: Assists in determining pathophysiologic causes for Disturbed
Vital signs Thought Process.
Neurologic status, particularly for signs and symptoms of ICP
Mental status
Laboratory values for metabolic alkalosis, hypokalemia,
increased ammonia levels, or infection
Collaborate with psychiatric nurse clinician and rehabilitation Collaboration provides the best plan of care.
nurse specialist.
Consistently provide a safe, calm environment: Basic safety measures and reinforcement of reality.
Provide siderails on bed.
Keep room uncluttered.
Reorient the client at each contact.
Reduce extraneous stimuli, e.g., limit noise and visitors, and
reduce bright lighting.
Use touch judiciously.
Prepare for all procedures by explaining simply and concisely.
(continued)
Copyright 2002 F.A. Davis Company
from home.
Design communications according to the patients best means Enhances communication and quality of care.
of communication, e.g., writing, visuals, or sound:
Give simple, concise directions.
Listen carefully.
Present reality consistently.
Do not challenge illogical thinking.
Encourage the patient to use prosthetic or assistive devices, e.g., Increases sensory input and reinforces reality.
eyeglasses, dentures, hearing aid, or walker.
Provide frequent rest periods. Reduces environmental stimuli that could contribute to confusion,
and helps to avoid sensory overload.
Provide consistent approach in nursing care and routine. Inspires trust, reinforces reality, decreases sensory stimuli, and
provides memory cues.
Encourage self-care to the extent possible. Increases self-esteem, forces reality check, decreases powerlessness,
and provides a means of evaluating the patients status.
Involve signicant others in care, and include in teaching Provides social support and consistency in management.
sessions.
Refer to and collaborate with appropriate assistive resources. Provides for long-term support and a more holistic approach
to care.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor cognitive capacity according to age and developmental Basic data needed to plan individualized care.
capacity.
Note discrepancies in chronologic age and mastery of
developmental milestones.
Provide ongoing reality orientation by encouraging the family As the patient attempts to reorient, it is helpful that date, time, and
to visit, and by emphasizing time, personal awareness, and specic concrete planning, hour by hour, are offered. The infant
gradual resumption of daily routine to degree possible. should be reintroduced to data, in a calm manner, that will assist in
regaining some control over the environment and in regaining the
previous functioning level so that he or she can continue to progress.
Provide anticipatory safety to reect greater range of potentials Disturbed Thought Process serves as a high-risk factor for all
according to psychomotor capacity. involved. It would be a reasonable standard of care to increase all
anticipatory safety efforts.
Encourage the family members to express concerns for the Promotes ventilation, which helps reduce anxiety and offers insight
childs condition by allowing 30 min each shift for discussion. into thoughts about the patients condition.
Provide for primary health needs, including administration of Attention to regular health needs must also be considered as the
medications, comfort measures, and control of environment to whole person is considered.
aid in the childs adaptation.
Structure the room in a manner that bets the childs needs. Keeping the environment adapted to personal needs will facilitate
care, minimize the chance for accidents, and demonstrate the
needed structure.
Allow for ample rest periods according to sleep patterns during Rest is a key and essential consideration to provide optimal
health and within parameters for age-related sleep needs. potential for cognitive-perceptual functioning.
Monitor for existence of other patterns, especially altered coping All contributing factors must be explored to ensure meeting the
and role performance. patients needs.
Assist the family in dismissal plans by utilization of appropriate Improves family adjustment and coping by assisting in preparing
state and community resources. for home needs. Empowerment then permits them the opportunity
for growth in coping skills and parenting.
If institutionalization is required, assist the family in learning Planning provides the means for coping and adjusting to the move
about related issues, such as vitiation, medical records with an opportunity for clarication. Provides advocacy for the
maintenance, prognosis, and risk factors. patient and family.
Maintain ethical and legal condentiality on the patients behalf. Standard practice must include safeguarding the patients needs for
condentiality and legal rights.
Allow for culturally unique aspects in management of care, e.g., Increases individuation and satisfaction with care. Shows respect
respect for visitation on religious holidays, family wishes for diet, for the familys values. Enhances nurse-patient relationship.
and bathing.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
This nursing diagnosis will pertain to the woman the same as any other adult, with the following excep-
tion. For midlife women, the nursing actions and interventions are the same as those given in Decient
Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern under the heading of perimenopausal and
menopausal life periods.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the clients level of anxiety, and refer to Anxiety Too much information can increase the clients confusion and
(Chap. 8) for detailed interventions related to this diagnosis. disorganization. The amount of time devoted to interaction should
be guided by the clients attention span.73
Speak to the client in brief, clear sentences.
Keep initial interactions short but frequent. Interact with client Facilitates the development of a trusting relationship.
for [number] minutes every 30 min. Begin with 5-min
interactions and gradually increase the times of interactions.
Assign the client a primary care nurse on each shift to assume Facilitates the development of a trusting relationship.
responsibility for gaining a relationship of trust with the client.
Be consistent in all interactions with the client. Facilitates the development of a trusting relationship, and meets the
clients safety needs.
Set limits on inappropriate behavior that increase the risk of the Client and staff safety are of primary importance.
client or others being harmed. Note the limits here as well as
revisions to the limits.
Initially place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to clients
sense of disorganization and confusion.
Orient the client to the environment, and assign someone to Promotes the clients safety needs while facilitating the development
provide one-to-one interaction while the client orients to unit. of a trusting relationship.
Do not make promises that cannot be kept. Facilitates the development of a trusting relationship.
Inform the client of your availability to talk with him or her; Communicates acceptance of the client, which facilitates the
do not pry or ask many questions. development of trust and self-esteem.
Do not argue with the client about delusions; inform the client Argument may reinforce the clients need to maintain the delusional
in a matter-of-fact way that this is not your experience of the system and interferes with the development of a trusting
situation, e.g., I do not think I am angry with you. relationship.
Recognize and support the clients feelings, e.g., You sound Focuses on the clients real feelings and concerns.
frightened.
Respond to the feelings being expressed in delusions or
hallucinations.
Initially have the client involved in one-to-one activities; as High levels of environmental stimuli may increase confusion and
conditions improve, gradually increase the size of the disorganization.
interaction group. Note current level of functioning here.
Have the client clarify those thoughts you do not understand. Facilitates the development of a trusting relationship, and prevents
Do not pretend to understand that which you do not. inadvertent support of the delusional thinking.
Do not attempt to change delusional thinking with rational This may encourage the client to cling to these thoughts.
explanations.
After listening to delusion once, do not engage in conversations Decreases the possibility of supporting or reinforcing the delusion.
related to this material or focus conversations on this material.
Focus conversations on here-and-now content related to real Facilitates the clients contact with reality.67
things in the environment or to activities on the unit.
Do not belittle or be judgmental about the clients delusional beliefs. Protects the clients self esteem.
Avoid nonverbal behavior that indicates agreeing with Decreases the possibility of supporting or reinforcing the delusion.
delusional beliefs.
When the clients behavior and anxiety level indicate readiness, Provides feedback about delusional beliefs from peers.
place the client in small-group situations. The client will spend
[number] minutes in group activities [number] times a day.
(continued)
Copyright 2002 F.A. Davis Company
Develop a daily schedule for the client that encourages focus on Facilitates the clients contact with reality. Promotes positive
here and now and is adapted to the clients level of functioning self-image.
so that success can be experienced. Note daily schedule here.
Assign the client meaningful roles in unit activities. Provide Facilitates the clients contact with reality. Promotes positive
roles that can be easily accomplished by the client to provide self-image.
successful experiences. Note client responsibilities here.
Primary nurse will spend [number] minutes with the client Assists in the development of alternative coping behaviors.
twice a day to discuss the clients feelings and the effects of the
delusions on the clients life. (Number of minutes and the
degree of exploration of the clients feelings will increase as the
client develops relationship with nurse.)
Provide rewards to the client for accomplishing task progress on Positive feedback encourages productive behavior.
the daily schedule. These rewards should be ones the client
nds rewarding.
Spend [number] minutes twice a day walking with the client. Facilitates the development of a trusting relationship. Social
This should start at 10-min intervals and gradually increase. interaction provides positive reinforcement. Helps increase
This can be replaced by any physical activity the client nds daytime wakefulness, promoting a normal sleep-wake cycle.
enjoyable. A staff member should be with the client during this
activity to provide social reinforcement to the client for
accomplishing the activity.
Arrange a consultation with the occupational therapist to assist Increases daytime wakefulness, maintaining a normal sleep-rest
the client in developing or continuing special interests. cycle.
Monitor delusional beliefs for potential of harming self or others. Patient and staff safety are of primary concern.
Note any change in behavior that would indicate a change in Patient and staff safety are of primary concern.
the delusional beliefs that could indicate a potential for violence.
If the client is placed in seclusion, interact with the client at Provides reality orientation, and assists the client with controlling
least every 15 min. hallucinations and delusions.
Maintain environment that does not stimulate the clients Excessive environmental stimuli can increase confusion and
delusions, e.g., if the client has delusions related to religion, disorganization.
limit discussions of religion and religious activity on unit to
very concrete terms. Limit interaction with persons who
stimulate delusional thinking.
Primary nurse will assist the client in identifying signs and Promotes the clients sense of control, and enhances self-esteem.
symptoms of increasing thought disorganization and in
developing a plan to cope with these situations before they
get out of control. This will be done in the regular scheduled
interaction times between the primary nurse and the client.
As the clients condition improves, primary nurse will assist the Facilitates the clients developing alternative coping behaviors.
client to identify onset delusions with periods of increasing anxiety.
As connection is made between thought disorder and anxiety, Promotes the clients sense of control, and enhances self-esteem.
the client will be assisted to identify specic anxiety-producing
situations and learn alternative coping behaviors. See Anxiety
(Chap. 8) for specic interventions.
Refer the client to outpatient support systems, and assist with Facilitates the clients reintegration into the community.
making arrangements for the client to contact these before discharge.
Gerontic Health
NOTE: Problems related to Disturbed Thought Process with older adults may present themselves in
various ways. Two conditions, dementia and delirium, are considered here. Irreversible dementia, such
as Alzheimers or multi-infarct dementia, is usually progressive, gradual in onset, of long duration, and
has a steady downward course. Delirium, or acute confusional state, presents with acute onset, is of
short duration, and has a uctuating course and is often reversible with treatment.74 Nursing inter-
ventions vary depending on the course of the Disturbed Thought Process.
ACTIONS/INTERVENTIONS RATIONALES
DEMENTIA
Maintain safe environment. Avoid leaving solutions, equipment, The patient is unable to determine the harmful consequences of
or medications near the patient that could result in injury misuse.
through misuse or ingestion.
(continued)
Copyright 2002 F.A. Davis Company
DELIRIUM
Monitor for conditions that can induce delirium. Certain factors such as electrolyte imbalance, preoperative
dehydration, unanticipated surgery, intraoperative hypotension,
postoperative hypothermia, and a large number of medications
have been found to be associated with acute confusional states in
older adults.75,76
Provide orienting information to the patient as often as necessary. Provides information to the patient about the current situation, and
assists in reducing anxiety and confusion.
Ensure that sensory decits are corrected to extent possible. Correcting sensory decits enhances the patients ability to use
available cues to person, place, and time.
Provide consistent staff. Avoids adding to confusion and promotes the patients security.
Provide sensory stimulation such as bathing, touching, and back Assists in restoring the patients sense of body image.77
massages.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family to monitor for signs and symptoms Basic monitoring that allows for early intervention.
of Disturbed Thought Process:
Poor hygiene
Poor decision making or judgment
Regression in behavior
Delusions
Hallucinations
Changes in interpersonal relationship
Distractibility
Involve the client and family in planning, implementing, and Involvement improves cooperation and motivation, thereby
promoting appropriate thought processing: increasing the probability of an improved outcome.
Family conference
Mutual goal setting
Communication
Assist the client and family in lifestyle adjustments that may be
necessary:
Providing safety and prevention of injury
Frequent orientation to person, place, and time
Providing reality testing and patient verication
Assisting in working through alterations in role functions in
family or at work
Stopping substance abuse
Facilitating family communication
Setting limits
Learning new skills
Decreasing risk for violence
Preventing suicide
Explaining possible chronicity of disorder
(continued)
Copyright 2002 F.A. Davis Company
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Frequently remind the patient to attend to both sides of his or Repetition improves brain processing.
her body.
Assist the patient to touch and feel neglected side of body. Help Increases brains awareness of neglected side.
the patient, by providing a variety of sensations (warmth, cool,
soft, harsh, etc.), to become more aware of and articulate
sensations on neglected side.
Assist the patient with ROM exercises to neglected side of body Increases brains awareness of neglected side, and maintains
every 4 h while awake at [times]. Teach extent of movement of muscle tone and joint mobility.
each joint on neglected side of body.
Help the patient position neglected side of body in a similar way
as attended side of body whenever position is changed.
Remind the patient to turn plate during each meal. Assists the patient to notice all of food, and increases cues to brain.
Turn every 2 h on [odd/even] hour. Monitor skin condition on Improves circulation. Relieves pressure areas. Avoids skin
each turning. breakdown on affected side.
Refer to rehabilitation nurse clinician. Collaboration provides a more holistic plan of care, and
rehabilitation nurse will have most up-to-date knowledge
regarding this diagnosis.
Copyright 2002 F.A. Davis Company
Child Health
See nursing actions under Disturbed Sensory Perception in addition to those listed here.
ACTIONS/INTERVENTIONS RATIONALES
Allow 30 min every shift for the patient and family to express Ventilation of feelings is paramount in understanding the effect the
how they perceive the unilateral neglect. problem has on the patient and the family; it is also critical as a
means of evaluating needs.
Determine how the unilateral neglect affects the usual expected Previous and/or current developmental capacity may be affected by
behavior or development for the child. the unilateral neglect depending on the degree of severity. To be
able to judge the best means of therapy requires these data to be
considered, e.g., does the child use the affected hand as a helper,
or not try to use it at all?
Monitor for presence of secondary or tertiary decits. Identication of primary decits should alert all to monitor for
possible secondary and tertiary decits to minimize further
sequelae, which can be treated early.
Establish, with family input, appropriate anticipatory safety Safety needs and measures must reect the developmental capacity
guidelines that are based on the unilateral neglect and the of the child and slightly beyond it. There is a special need to
developmental capacity of the child. structure the environment to allow for appropriate exploratory
behavior while maintaining safety without overprotection.
Stress appropriate follow-up prior to dismissal from hospital Arrangement for follow-up increases the likelihood of compliance
with appropriate time frame for the family. and shows the importance of follow-up.
Womens Health
This nursing diagnosis will pertain to women the same as any other adult.
Psychiatric Health
Nursing interventions for this diagnosis are those described in Adult Health.
Gerontic Health
The nursing orders for the older adult with this diagnosis are the same as those for Adult Health.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to Unilateral Neglect, e.g., This action provides the database needed to identify interventions
disturbed perceptual abilities, neurologic disease, or trauma. that will prevent or diminish unilateral neglect.
Involve the client and family in planning, implementing, and Family involvement is important to ensure success. Communication
promoting reduction in effects of Unilateral Neglect: and mutual goals improve the outcome.
Schedule family conferences, e.g., to discuss concerns family
members have.
Encourage the familys ideas for addressing the concern.
Set mutual goals, e.g., establish two measures to offset the effect
of unilateral neglect. Be sure roles for the participants are
identied.
Maintain communication.
Provide support for the caregiver, e.g., plan respite time for
the primary caregiver. Alternate caregivers are identied and
trained.
Teach the client and family measures to decrease effects of These actions diminish the negative effects of Unilateral Neglect.
Unilateral Neglect:
Active and passive ROM exercises
Ambulation with assistive devices (canes, walkers, or crutches)
Objects placed within eld of vision and reach
Assistive eating utensils
Assistive dressing equipment
Safe environment, e.g., objects removed from area outside
eld of vision
Assist the family and client to identify lifestyle changes that may Lifestyle changes require changes in behavior. Self-evaluation and
be required: support facilitate these changes.
Change in role functions
Coping with disability or dependency
(continued)
Copyright 2002 F.A. Davis Company
Unilateral Neglect
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., now paying Reassess using initial assessment factors.
attention to care of affected side;
utilizes safety precautions for
affected side; presenting no signs
or symptoms of Unilateral Neglect.
Record RESOLVED. Delete nursing
diagnosis, expected outcome,
target date, and nursing actions No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 8
Self-Perception and
Self-Concept Pattern
admission? b. No
a. Yes (Disturbed Body Image) 13. Does the patient have a problem with physical or social isola-
b. No tion?
5. Does the patient express fear about dying? a. Yes (Risk for Loneliness)
a. Yes (Death Anxiety) b. No
b. No 14. Has the patient recently suffered the loss of a signicant other?
451
Copyright 2002 F.A. Davis Company
a. Yes (Risk for Loneliness) known. Mead5 expressly addresses the development of these mem-
b. No ories and how they affect ones behavior.
15. Does the patient verbalize lack of control? Mead5 describes the self-concept as evolving out of interactions
a. Yes (Powerlessness) with others in social contexts. This process begins at the moment
b. No of birth and continues throughout a lifetime. The denition of self
16. Is the patient participating in care and decision making re- can only occur in social interactions, for ones self exists only in re-
garding care? lation to other selves. The individual is continually processing the
a. Yes reactions of others to his or her actions and reactions. This pro-
b. No (Powerlessness) cessing is taking place in a highly personalized manner, for the in-
formation is experienced through the individuals selective atten-
Conceptual Information tion, which is guided by the current needs that are struggling to be
expressed. This results in an environment that is constructed by
Denition of the self and of a self-concept has been an issue of de- ones perceptions. Meads conceptualization leads to an interesting
bate in philosophy, sociology, and psychology for many years, and feedback process in that we can only perceive self as we perceive
many publications are available on this topic.1 The complexity of others perceive us. This continues to reinforce the idea that the self-
the problem of dening self is compounded by the knowledge that concept is highly personalized.
external observation provides only a supercial glimpse of the self, Many authors2,4,5 have addressed the process of developing a
and introspection requires that the knower knows himself or her- concept of self. The model developed by Harry Stack Sullivan6 is
self so that information actually gained is self-referential. In spite of presented here because it is consistent with the information pre-
these problems, the concept continues to be pervasive in the liter- sented in the symbolic interaction literature and is used as the the-
ature and in the universal experience of self or not self. Intu- oretical base in much of the nursing literature.
itively one would say, of course, There is a self because I have ex- Sullivan6 describes the self-concept as developing in interactions
periences separate from those around me; I know where I end and with signicant others. Sullivan sees development of the self-
they begin. The importance of self is also emphasized by the lan- concept as a dynamic process resulting from interpersonal interac-
guage in the multitude of self-referential terms such as self-actual- tions that are directed toward meeting physiologic needs. This
ization, self-afrmation, ego-involvement, and self-concept. process has its most obvious beginnings with the infant and be-
Turner2 addresses societys need for the individual to conceptu- comes more complex as the individual develops. This increasing
alize the self-as-object. Recognizing the self-as-object allows society complexity results from the layering of experiences that occurs in
to place responsibility, which becomes a very valuable asset in the developing individual. The biologic processes become less and
maintaining social control and social order. This returns us to the less important in directing the individual the further away from
initial problem of what the self is and how we can understand oth- birth one is and as the importance of interpersonal interaction in-
ers selves and ourselves.3 creases. The initial interpersonal interaction is between the infant
In this section, the assumption is made that self-concept refers to and the primary caregivers. An infant expresses discomfort with a
the individuals subjective cognitions and evaluations of self; thus, cry and the parenting one responds. This response, whether it be
it is a highly personal experience. This indicates that the self is a tender or harsh, begins to inuence the infants beliefs about her-
personal construct and not a fact or hard reality. It is further as- self or himself and the world in general. If the interaction does not
sumed that the individual will act, as stated earlier, in congruence provide the infant with a feeling of security, anxiety results and in-
with the self-concept. This conceptualization is consistent with the terferes with the progress toward other life goals. Sullivan makes a
authors who will be discussed and with the assumptions utilized in distinction between the inner experience and the outer event and
psychological research.3 It is also important to recognize that lan- describes three modes of understanding experience.
guage assists in developing a concept. This becomes crucial when The rst developmental experience is the prototaxic mode. In this
thinking about the concept of self in English, because the English mode, the small child experiences self and the universe as an un-
language comes from a tradition of Cartesian dualism that does not differentiated whole. At 3 to 4 months, the child moves into the
express integrated concepts well. Often it will appear that the in- parataxic mode. The parataxic mode presents experiences as sepa-
formation presented is separating the individual into various parts, rated but without recognition of a connectedness or logical se-
when, in fact, an integrated whole is being addressed. For example, quence. Finally, the individual enters the syntaxic mode, in which
James4 talks about an I and Me. If these terms were taken at face consensual validation is possible. This allows for events and expe-
value, it would appear that the individual is being divided into mul- riences to be compared with others experiences and for establish-
tiple parts, when, in fact, an integrated whole is being discussed and ment of mutually understandable communication instead of the
the words describe patterns of the whole person. Unless otherwise autistic thinking that has characterized the previous stages.7,8
stated, it can be assumed that the concepts presented in this book As one experiences the environment through these three modes
reect on the individual as an integrated whole. of thought, the self-system or self-concept is developed. Sullivan
Symbolic interaction theory provides a basis for understanding conceptualized three parts of the self. The part of the self that is as-
the self. James4 and Mead5 developed the foundation for the self in sociated with security and approval becomes the good me. That
this theoretical model. James outlines the internal working of the which is within ones awareness but is disapproved of becomes the
self with his concepts of I and Me. I is the thinker or the state bad me. The bad me could include those feelings, needs, or de-
of consciousness. Me is what the I is conscious of and includes sires that stimulate anxiety. Those feelings and understandings that
all of what people consider theirs. This Me contains three aspects: are out of awareness are experienced as not me. These not me
the material me, the social me, and the spiritual me.4 The self- experiences are not nonexistent but are expressed in indirect ways
construction outlined by Mead5 indicates that there is the knower that can interfere with the conduct of the individuals life.6,7
part of the self and that which the knower knows. Mead concep- As the social sciences adopted a cybernetic worldview, this the-
tualizes the thoughts themselves as the knower to resolve the oretical perspective has been applied to developing a concept of
metaphysical problem of who the I is. In Meads writings, the con- self. Glasersfeld9 spoke of the self as a relational entity that is given
sciousness of self is a stream of thought in which the I can re- life through the continuity of relating. This relating provides the in-
member what came before and continues to know what was
Copyright 2002 F.A. Davis Company
Thus, it is important that children have certain fears to protect them continue throughout life with each new interaction in each new ex-
from harm. The hot stove, for example, should produce a fear re- perience. Thus, the child learns from primary caregivers that his or
sponse to the degree that it prevents the child from touching the her expressions of need may or may not have an effect on those
stove and being injured. Fear is a learned response to situations, around him or her and also learns what must be done to have an
and children learn this response from their caregivers. Thus, it be- effect. If the caregiver responds to the earliest cries of the infant, a
comes the caregivers responsibility to model and teach appropri- sense of personal inuence has begun. The two areas that consis-
ate fear. If a mother cannot tolerate being left alone in the house at tently inuence ones perceptions of inuence are discipline and
night with her children, her children will learn to fear being in this communication styles.
situation. When this home is located in a low-crime area with sup- Implementation of discipline in a manner that provides the child
portive neighbors and appropriate locks, fear becomes an inappro- with a sense of control over the environment while teaching appro-
priate response, and the children may be affected by it for a lifetime. priate behavior can produce a perception of mutual system inuence.
Various developmental stages have characteristic fears associated Harsh, overcontrolling methods can produce the perception that the
with them. In the mind of the child, these characteristic fears pre- child does not have any inuence in the system if acting in a direct
sent threats, so the fears can be seen both as a source of fear and as manner. This produces an indirect inuencing style. An example of
a source of anxiety. The characteristic fears result from strong or indirect inuence is the child who always becomes ill just before his
noxious environmental stimuli such as loud noises, bright lights, or parents leave for an evening on the town. The parents, out of concern
sharp objects against the skin. The response to fears produces phys- for the child, decide to remain at home and thus never have time to-
iologic symptoms. The most immediate and obvious response is gether as a couple. Authoritarian styles of interaction can also pro-
crying and pulling away from the stressful object or situations. duce perceptions of powerlessness in adults in unfamiliar environ-
Erickson23,24 indicated that he thought hope evolved out of the ments. If the hospital staff acts in an authoritarian manner, the client
successful resolution of this rst developmental stage, basic trust may develop perceptions of powerlessness.
versus mistrust. Hope was perceived by Erickson to be a basic hu- Double-bind communication can place the individual in a posi-
man virtue. The type of environment that has been identied as tion of feeling that no matter what action I take, it appears to be
promoting the development of this basic trust is warm and loving, wrong, and also can produce a perception of powerlessness. They
where there is respect and acceptance for personal interests, ideas, are damned if they do and damned if they dont. If the individual
needs, and talents.21 Several environmental conditions have been cannot inuence this system in a direct manner, again, indirect be-
associated with early childhood and are seen as increasing the per- havior patterns are chosen. Bateson26 proposes that this is the process
ceptions consistent with hopelessness. These conditions are eco- behind the symptom cluster identied as schizophrenia. This sug-
nomic deprivation, poor physical health, being raised in a broken gests that if the child is continually placed in the position of being
home or a home where parents have a high degree of conict, hav- wrong no matter what he or she has done, the child could develop
ing a negative perception of parents, or having parents who are not the perception that his or her position is one of powerlessness and
mentally healthy. From an existential perspective, Lynch25 identi- carry this attitude with him or her throughout life.
ed ve areas of human existence that can produce hopelessness. Infants have a need for consistent response to having physiologic
If these areas are not acknowledged in the developmental process, needs met, and the most important relationship becomes that with
the individual is at greater risk of frustration and hopelessness be- the parenting one. If this relationship is disrupted and needs are
cause hope is being intermingled with a known area of hopeless- not met, symptoms related to infant depression or failure to thrive
ness. The ve areas that Lynch identied are death, personal im- could communicate a perception related to powerlessness.
perfections, imperfect emotional control, inability to trust all It is important to remember that self-concept, including body
people, and personal areas of incompetence. This supports Erick- image, is developed throughout life. For the infant, the primary
sons contention that hope evolves out of the rst developmental source of developing self-concept and body image is physical in-
stage, because these basic areas of hopelessness are issues primar- teraction with the environment. This includes both the environ-
ily related to the resolution of trust and mistrust. It should be re- ments response to physical needs and the bodys response to envi-
membered that previously resolved or unresolved developmental ronmental stimuli.
issues must be renegotiated throughout life. Some behaviors that build assets in the infant and toddler in-
Each developmental stage has a set of specic etiologies and clude playing with the child at eye level; exposing the child to pos-
symptom clusters related to hopelessness. Because the relationship itive values by modeling sharing and being nice to others; reading
between self-concept strength and degree of hopefulness is seen as to them; providing a safe, caring, stimulating environment; and
a positive link, many of the etiologies and symptoms of hopeless- communicating to the child that he or she is important by spend-
ness at the various developmental stages are similar to those of self- ing time with him or her.27
esteem disturbances.22
As conceptualized by Erickson,24 infancy is the primary age for de- TODDLER AND PRESCHOOLER
veloping a hopeful attitude about life. If the infant does not experi-
ence a situation in which trust in another can be developed, then the The basic sources of anxiety remain the same as for the infant. Sepa-
base of hopelessness has begun. Thus, if the infant experiences fre- ration anxiety appears to peak again at 18 to 24 months, and stranger
quent change in caregivers or has a caregiver who does not meet the anxiety peaks again at 12 to18 months. Loss of signicant others is
basic needs in a consistent and warm manner, the infant will become the primary source of anxiety at this age. In addition to the physio-
hopeless. Research25 has indicated that children who have been logic responses already mentioned, the child may demonstrate anxi-
raised in an environment of despair are at greater risk for experienc- ety by motor restlessness and regressive behavior. The preschooler
ing hopelessness. Symptoms of hopelessness in infants resemble in- can begin to tolerate longer periods away from the parenting one and
fant depression or failure to thrive. Because symptoms in infants are enjoys having the opportunity to test his or her new abilities. Lack of
a general response, the diagnosis of Hopelessness must be considered opportunity to practice independent skills can increase the discom-
equally with other diagnoses that produce similar symptom clusters fort of this age group. Increased anxiety can be seen in regressive be-
such as Powerlessness and Ineffective Coping. havior, motor restlessness, and physiologic response.
Ones perceptions of place in the larger system and of inuence Sources of anxiety can include concerns about the body and body
in this system begin at birth. These perceptions are developed mutilation, concerns about death, and concerns about loss of self-
through interactions with those in the immediate environment and control. These concerns can be expressed in the ways previously dis-
Copyright 2002 F.A. Davis Company
thought, and as a result they could develop reasonable models of self-perceptions. Perceived failures in meeting role expectations can
hopefulness. This cognitive process occurs in conjunction with a lack produce negative self-evaluation. The number of roles a person has
of a variety of life experience and self-discipline and with a height- assumed and the personal, cultural, and support system value
ened state of emotionality. This can result in a situation in which the placed on the identied roles determine the threat that negative
immediate goal can overshadow future consequences or possibilities. evaluation of performance can be to self-perception. Cultural value
An adolescent who appears very hopeful when cognitive functioning and personal identity formation determine the degree to which
is not overwhelmed by emotions can be lled with despair when in- body image remains important in providing a positive evaluation of
volved in a very emotional situation. Consideration of this ability is self. The adult endows unique signicance to various body parts.
important when caring for this age group. It is important to distin- This valuing process is personal and is often not in personal aware-
guish problem behavior from normal behavior and mood swings. ness until there is a threat to the part.
Kinds of behavior that could indicate problems in this area include
withdrawal and increased or amplied testing of limits. Situations OLDER ADULT
that affect the peer group hope can place the adolescent at great risk.
Again, issues of dependence-independence assume a primary As the older adult continues to age, he or she faces numerous chal-
role. The focus of this struggle is dependence on peers and inde- lenges to self-perception and self-concept. Roles may change sec-
pendence from family. The challenge for the adolescent becomes ondary to retirement or loss of signicant others, such as a spouse
achieving what Erickson and Kinney28 refer to as afliated indi- or child. Financial resources may become limited or xed as a re-
viduation. This requires that they learn how to be dependent on sult of illness, retirement, or loss of spouse.31 Chronic illness that
support systems while maintaining their independence from these necessitates a decrease in social interactions or increased depen-
same support systems and feeling accepted in both positions. dence on others and the resulting loss of control has a negative im-
Body image becomes a crucial area of self-evaluation because of pact on self-esteem for some elderly.32
changing physical appearance and heightened sexual awareness. Negative societal feedback, such as ageism, sends a message to
This evaluation is based on the cultural ideal as well as that of the older adults that they are somehow no longer valuable to the soci-
peer group. Perceived personal failures are often attributed to phys- ety. In the face of these decremental losses, it is necessary to con-
ical differences. sider what health care professionals can do to assist the older adult
The importance of a positive self-concept for adolescents is high- in maintaining a positive regard for self.
lighted by research that indicates a complex relationship between
self-concept, psychological adjustment, and behavior. Most signif-
icant is the consistent nding that low self-concept leads to a greater APPLICABLE NURSING DIAGNOSES
incidence of delinquency. This relationship appears to be strongest
with factors that are associated with the moral-ethical self-concept.29
Theoretical explanations for this phenomenon consider the behav- Anxiety
ior as a method for balancing the negative view of self or as part DEFINITION
of a cycle of punishment resulting in shame, guilt, and expulsion
rather than reconstruction.29 This link between self-concept and A vague uneasy feeling of discomfort or dread accompanied by an
the complex of behaviors termed delinquency increases the impor- autonomic response; the source is often nonspecic or unknown to
tance of providing adolescents with asset-building experiences. the individual; a feeling of apprehension caused by anticipation of
Assets important for adolescents include family love and support, danger. It is an alerting signal that warns of impending danger and
parent involvement in schooling, positive family communication, enables the individual to take measures to deal with threat.33
caring school environment, useful community roles, safe commu-
nity environment, clear rules and consequences, positive adult role NANDA TAXONOMY: DOMAIN 9COPING/STRESS
models, participation in creative activities, involvement in commu- TOLERANCE; CLASS 2COPING RESPONSES
nity activities, spending most evenings at home, positive learning
experiences, development of planning and decision-making skills, NIC: DOMAIN 3BEHAVIORAL; CLASS T
development of interpersonal skills, development of a sense of per- PSYCHOLOGICAL COMFORT PROMOTION
sonal power, a sense of purpose, and a positive view of the future.27 NOC: DOMAIN IIIPSYCHOSOCIAL HEALTH;
Specic asset-building behaviors can include asking teens for their CLASS OSELF CONTROL
opinion or advice, helping teens to contribute to their communi-
ties, encouraging them to assume leadership roles in addressing is-
sues that are of concern to them, talking with teens about their
DEFINING CHARACTERISTICS33
goals, providing challenging learning opportunities, providing in- 1. Behavioral
creasing opportunities for teens to make their own decisions, cele- a. Diminished productivity
brating their accomplishments, providing listening time, learning b. Scanning and vigilance
their names, and asking them about their interests.30 c. Poor eye control
d. Restlessness
ADULT e. Glancing about
f. Extraneous movement (e.g., foot shufing and hand and arm
Changes in role and relationship patterns generate the fears specic movements)
to these age groups. These could include parenthood, marriage, di- g. Expressed concerns due to change in life events
vorce, retirement, or death of a spouse. Fear expression in these age h. Insomnia
groups produces cognitive and affective symptoms similar to those i. Fidgeting
described for the adolescent. 2. Affective
A specic developmental crisis can produce a perception of a. Regretful
hopelessness and powerlessness. The situations that place the adult b. Irritability
at risk are marriage, pregnancy, parenthood, and divorce. c. Anguish
Concerns about role performance assume an important role in d. Scared
Copyright 2002 F.A. Davis Company
ANXIETY 457
e. Jittery a. Blocking of thought
f. Overexcited b. Confusion
g. Painful and persistent increased helplessness c. Preoccupation
h. Rattled d. Forgetfulness
i. Uncertainty e. Rumination
j. Increased wariness f. Impaired attention
k. Focus on self g. Decreased perceptual eld
l. Feelings of inadequacy h. Fear of unspecied consequences
m. Fearful i. Tendency to blame others
n. Distressed j. Difculty concentrating
o. Worried, apprehensive k. Diminished ability to problem solve and learn
p. Anxious l. Awareness of physiologic symptoms
3. Physiologic m. Focus on self
a. Voice quivering n. Expressed concerns due to changes in life events
b. Increased respiration (sympathetic)
c. Urinary urgency (parasympathetic) RELATED FACTORS33
d. Increased pulse (sympathetic)
e. Pupil dilation (sympathetic) 1. Exposure to toxins
f. Increased reexes (sympathetic) 2. Threat to or change in role status
g. Abdominal pain (parasympathetic) 3. Familial association or heredity
h. Sleep disturbance (parasympathetic) 4. Unmet needs
i. Tingling in extremities (parasympathetic) 5. Interpersonal transmission or contagion
j. Increased tension 6. Situational or maturational crises
k. Cardiovascular excitation (sympathetic) 7. Threat of death
l. Increased perspiration 8. Threat to or change in health status
m. Facial tension 9. Threat to or change in interaction patterns
n. Anorexia (sympathetic) 10. Threat to or change in role function
o. Heart pounding (sympathetic) 11. Threat to self-concept
p. Diarrhea (parasympathetic) 12. Unconscious conict about essential values or goals in life
q. Urinary hesitancy (parasympathetic) 13. Threat to or change in environment
r. Fatigue (parasympathetic) 14. Stress
s. Dry mouth (sympathetic) 15. Threat to or change in economic status
t. Weakness (sympathetic) 16. Substance abuse
u. Decreased pulse (parasympathetic)
v. Facial ushing (sympathetic) RELATED CLINICAL CONCERNS
w. Supercial vasoconstriction (sympathetic)
x. Twitching (sympathetic) 1. Any hospital admission
y. Decreased blood pressure (parasympathetic) 2. Failure to thrive
z. Nausea (parasympathetic) 3. Cancer or other terminal illnesses
aa. Urinary urgency (parasympathetic) 4. Crohns disease
bb. Faintness (parasympathetic) 5. Impending surgery
cc. Respiratory difculties (sympathetic) 6. Hyperthyroidism
dd. Increased blood pressure (sympathetic) 7. Substance abuse
4. Cognitive 8. Mental health disorders
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Obtain a thorough history upon admission. Allows identication of all possible contributing factors to
anxiety.
Monitor anxiety behavior and relationship to activity, events, When anxiety increases, the ability to follow instruction or
people, etc. every 2 h on [odd/even] hour. cooperate in plan of care decreases. Identication of the behavior
and causative factors enhances intervention plans.
Reassure the patient that anxiety is normal. Assist the patient to Helps identify connection between the precipitating cause and the
learn to recognize and identify the signs and symptoms of anxiety experience; reassures the patient that he or she is not
anxiety, e.g., hyperventilation, rapid heartbeat, sweaty palms, going crazy.
inability to concentrate, and restlessness.
Provide calm, nonthreatening environment: Conveys calm and helps the patient focus on conversation or
Explain all procedures and rationale for procedure in clear, activity.
concise, simple terms.
Decrease sensory input and distraction, e.g., lighting or
noise.
Encourage signicant other(s) to stay with the patient but not
Monitor vital signs at least every 4 h while awake at [times]. Assists in determining the effects of anxiety. Helps determine
pathologic effects of anxiety.
Attend to primary physical needs promptly. Conserves the patients energy, and allows the patient to focus on
coping with and reducing anxiety. Failure to attend to physical
needs would serve to increase anxiety.
Administer antianxiety medications as ordered. Monitor and Effectiveness of medication is determined so modication can be
document effects of medication within 30 min of administration. provided if needed. Medication helps reduce anxiety to a
manageable level.
Collaborate with psychiatric nurse clinician regarding care (see Collaboration helps provide holistic care. Specialist may help
Psychiatric Health nursing actions). discover underlying events for anxiety and assist in designing an
alternate plan of care.
Refer the patient to and collaborate with appropriate community Support groups can provide ongoing assistance after discharge.
resources.
Copyright 2002 F.A. Davis Company
ANXIETY 459
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Review, with the child and parents, coping measures used for The identication of coping strategies provides essential information
daily changes and crises. to deal with anxiety. Once they are identied, the nurse can begin
to evaluate those strategies that are effective.
Identify ways the parents can assist the child to cope with A major starting point is to describe the feelings and attempt to
anxiety, e.g., set realistic explanations or demands and avoid create a sense of control, which is more likely in patients of a
bribing or not telling the truth. certain developmental capacity, e.g., those capable of abstract
thinking. In younger infants, rocking can provide soothing
repetitious notion when all other measures seem not to have
calmed the infant.
Adapt routine to best help the child regain control, e.g., use of Allowing the child to plan for meals or snacks with choices when
speech according to situation and simple but rm speech pattern. possible or structuring the room to offer a sense of self is conducive
to empowerment.
Modify procedures, as possible, to help reduce anxiety, e.g., do Unnecessary pain or invasive procedures make overwhelming
not use intramuscular injection when an oral route is possible. demands on the already stressed hospitalized child.
Use the childs developmental needs as a basis for care, especially The developmental level of the patient serves to guide the nurse in
for ventilation of anxiety, e.g., use of toys. care. A holistic approach is more likely to meet holistic health needs.
Allow the child and parents adequate time and opportunities to Appropriate time in preparation offers structure and allows focused
handle required care issues and thus reduce anxiety, e.g., when attention, which empowers and helps reduce anxiety as efforts are
painful treatments must be done, prepare all involved according directed to what is known.
to an agreed-upon plan.
Encourage the family to assist with care as appropriate, including Family involvement provides a sense of empowerment and growth
feeding, comfort measures, and stories. in coping, thereby reducing anxiety and promoting a sense of
Offer sufcient opportunities for rest according to age and sleep Proper attention to rest for each individual child will foster coping
requirements. capacities by conserving energy for coping.
Identify knowledge needs, and address these by having the family Allows teaching opportunity that increases the patients and familys
explain what they understand about treatments, procedures, knowledge about situation, which assists in reducing anxiety.
needs, etc.
Point out and reinforce successes in conquering anxiety. Positive reinforcement assists in learning.
Assist the patient and family to apply coping in future potential Allows practice in a non-anxiety-producing environment. Increases
anxiety-producing situations by presenting possible scenarios skill in using coping strategy. Empowers the patient and family.
that would call for utilization of the new skills, e.g., someone
pushes ahead of you in line, or a salesperson is rude to you.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
ANXIETY 461
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Monitor the infant and parents for attachment behaviors.
Refer the parents to appropriate resources for support and
further follow-up:
Lactation consultants
Primary care provider (obstetrician, pediatrician, certied
nurse midwife, family practitioner, or nurse practitioner)
MIDLIFE WOMEN
Provide information about hormone inuences on sleep
disorders, cardiac and mental functioning, and perceptions
of anxiety.36
Refer the client to appropriate resources for support and further
follow-up:
Physicians well versed in womens health
Womens health centers
Alternative health centers
Menopause and midlife centers:
Her Place
Dallas817-355-8008
Tucson520-797-9131
216-442-4747
1-900-372-5600
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Provide a quiet, nonstimulating environment that the client Inappropriate levels of sensory stimuli can contribute to the
perceives as safe. For the client experiencing severe or panic clients sense of disorganization and confusion.
anxiety, this may be a seclusion setting. This may include
providing objects that symbolize safety to the client. (Note here
the special environmental adaptations necessary for this client.)
Provide frequent, brief interactions that assist the client with Appropriate levels of sensory stimuli promote the clients sense of
orientation. Verbal information should be provided in simple, control.
brief sentences.
If the client is experiencing severe or panic anxiety, provide Communicates acceptance of the client, which facilitates the
support in a nondemanding atmosphere. development of trust and self-esteem.
If the client is experiencing severe or panic anxiety, provide a High levels of anxiety decrease the clients ability to process
here-and-now focus. information.
Provide the client with a simple repetitive activity until anxiety High levels of anxiety decrease the clients ability to problem solve.
decreases to the level at which learning can begin. Promotes the clients sense of control.
If the client is hyperventilating, guide him or her in taking slow, Reestablishes a normal breathing pattern, and promotes the clients
deep breaths. If necessary, breathe along with the client, and sense of control.
provide ongoing, positive reinforcement.
Approach the client in a calm, reassuring manner, assessing the Anxiety is contagious and can be communicated from the social
caregivers level of anxiety and keeping this to a minimum. network to the client.
Provide a constant, one-to-one interaction for the client Presence of a calm, trusted individual can promote a sense of
experiencing severe or panic anxiety. This should preclude control and calm in the client.
use of physical restraints, which tend to increase the clients
anxiety.
(continued)
Copyright 2002 F.A. Davis Company
ANXIETY 463
(continued)
ACTIONS/INTERVENTIONS RATIONALES
When signs of increasing anxiety are observed, talk the client Repeated practice of a behavior internalizes and personalizes the
through one of the coping strategies they have identied. (Note behavior.
here the clients symptoms of anxiety that are to be addressed
and the identied coping strategy.)
Provide the client with a written list of appointments that have Provides visible documentation of the importance of follow-up.
been scheduled for outpatient follow-up. Increases likelihood that appointments will be kept.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor daily for side effects of antianxiety agents if prescribed. The potential for side effects and drug interactions are increased
with older adults because of the decreased metabolism of drugs.
Identify environmental factors that may increase anxiety, such The environmental factors mentioned, if not addressed, induce
as noise level, harsh lighting, and high trafc ow. more stress in the older individual.
Provide direct, basic information on usual routines and May help decrease autonomic nervous system activity and feelings
procedures. of anxiety.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family appropriate monitoring of signs and Provides baseline data for early recognition and intervention.
symptoms of anxiety:
Increased pulse
Sleep disturbance
Fatigue
Restlessness
Increased respiratory rate
Inability to concentrate
Short attention span
Feeling of dread
Faintness
Forgetfulness
Involve the client and family in planning and implementing Family and client involvement enhances effectiveness of
strategies to reduce and cope with anxiety: intervention.
Family conference: Identication of sources of anxiety and
interventions designed to decrease anxiety
Communication
Assist the client and family in lifestyle adjustments that may be Lifestyle changes require changes in behavior. Self-evaluation and
required: support facilitate these changes.
Relaxation techniques, e.g., yoga, biofeedback, hypnosis,
breathing techniques, or imagery
Problem-solving techniques
Crisis intervention
Maintaining the treatment plan of health care professionals
who are guiding the therapy
Assist the client and family to set criteria to help them determine Early identication of issues requiring professional evaluation will
when the intervention of a health care professional is required, increase the probability of successful interventions.
e.g., inability to perform activities of daily living or threat to
self or others.
Teach the client and family purposes, side effects, and proper Provides necessary information for self-care.
administration techniques of medications.
Consult with or refer to assistive resources as indicated. Use of existing community services; provides for effective utilization
of resources.
Copyright 2002 F.A. Davis Company
Anxiety
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for pain every 2 h on [odd/even] hour. Administer Uncontrolled pain contributes signicantly to problems with body
analgesics. Monitor effectiveness of analgesic within 30 min of functioning, thus promoting the development and continuation of
administration, and use noninvasive techniques to keep pain Disturbed Body Image.
under control.
Use anxiety-reducing techniques as often as needed. Assists the patient in adapting to the changed body image.
Stay in frequent contact with the patient: Promotes verbalization of feelings, and allows consistent
intervention.
Be honest with the patient. Any dishonesty in terms of recovery, return of function, or
rehabilitation needs causes the patient to distrust caregivers and
promotes maintenance of body image disturbance.
Point out and limit self-negation statements. Self-negating statements prolong the problem and interfere with
rehabilitation potential.
Do not support denial. Focus on reality and adaptation (not The patient does not have to accept the problem, but he or she
necessarily acceptance). does have to, and can, adapt to the problem.
Set limits on maladaptive behavior. Maladaptive behavior supports the continuation of Disturbed
Body Image.
Focus on realistic goals. Supports continued progress. Allows positive feedback for
achievement, and permits the patient to see progress.
Be aware of own nonverbal communication and behavior. Any avoidance behavior or nonverbal communication that
Avoid moral, value judgments. indicates dismay would support the patients idea of his or her
unacceptability as a damaged person.
Assist and encourage the patient to look at and use affected Helps the patient attend to altered body image constructively, and
body part during activities of daily living. assists the patient to accept himself or herself.
Promote calm, safe environment throughout hospitalization. When using adaptive equipment, the patients safety must be
foremost. A calm environment allows the patient to focus on
working with the equipment or techniques without undue
pressure.
Collaborate with psychiatric nurse clinician regarding care as Collaboration promotes a holistic care plan and hastens solving of
needed (see Psychiatric Health nursing actions). the patients problem.
Teach the patient and signicant others self-care requirements. Helps the patient adapt to body change, and improves self-care
management. Provides support for self-care, and assists signicant
others to adapt also.
Encourage the patient to use available resources: Facilitates adaptation and decreases isolation. Provides long-term
Prosthetic devices support.
Assistive devices
Reconstructive and corrective surgery
Occupational therapy
Physical therapy
Rehabilitation services
Refer to and collaborate with community resources. Provides long-term support. Cost-effective use of already available
support.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributory factors for Disturbed Body Image, e.g., Provides database needed to more accurately plan interventions.
disgurement or perceived disgurement. (The family may
perceive such on behalf of the young infant or child.)
Utilize developmentally appropriate communication to assess Developmental capacity has to guide the interaction to gain accurate
and determine exact expression of Disturbed Body Image, e.g., information.
use puppet play or constructive dialogue with the
toddler.
Provide factual information to assist in dealing with Disturbed Knowledge serves to reduce anxiety and assists the patient to cope.
Body Image, e.g., availability of assistive devices or surgery. Provides options to assist in decision making.
(continued)
Copyright 2002 F.A. Davis Company
NOTE: In some instances, such as an infant or child with an anomaly or a condition offering no hope
of resolution, this alteration may accompany other disturbances such as self-esteem, parental coping,
and loss.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Spend [number] minutes with the client at [times] discussing Promotes the clients sense of control, and provides information
perception of disruption in lifestyle necessitated by change. that can be utilized in developing a plan of care that will t within
the clients perception of self.
Discuss with the client meaning of loss or change from a Expression of feelings in an accepting environment can facilitate
personal and cultural perspective. the clients problem solving.
Discuss with the client his or her signicant others reaction to Support system understanding and support can facilitate the
loss or change. clients adjustment.
Set an appointment to discuss with the client and signicant Expression of feelings and concerns in an accepting environment
others effects of the loss or change on their relationships. (Time can facilitate problem solving.
and date of appointment and all follow-up appointments should
be listed here.)
Provide the client with information on bingeing and purging Provides the client with increased information about his or her
and the impact they have on dieting and the body. behaviors.39 Do not impact calorie loss because of physiology of
digestion and destruction of tissue.
Have the client develop a daily food diary that records time of Assists clients with linking thoughts with behaviors.39
day, amount and type of food, and binge or purge with feelings
and thoughts.
Assess the client for suicidal thoughts or depression relating to Change in body shape can negatively impact self-esteem and
weight gain. increase feelings of depression.40
Spend [number] minutes with the client each day to focus on Cognitive maps inuence behavior.40
values, thoughts, and feelings that perpetuate body image
problems.
Spend [number] minutes each day to discuss assertive Assists in developing appropriate interpersonal boundaries.39
communication skills and practice these with the client. Note
specic behaviors to be practiced here.
Discuss with the client role exercise plays in health, and develop Provides the client with the information necessary to make healthy
an appropriate exercise plan. (Note here the plan for this lifestyle choices.
client.)
Schedule time with the clients signicant other to assess his or Support assists with the development of lifestyle changes.
her perception of the client and provide him or her with the
necessary information to support the clients change. Note
here the time and person responsible for this meeting.
Spend [number] minutes with the client at [times] to assist with Promotes the clients sense of control, and enhances self-esteem.
efforts to enhance appearance.
Provide physical activities 2 times per day at [times] that provide Assists the client in developing a new perception of body.
the client opportunities to dene boundaries of body. These
activities should be ones the client identies as enjoyable and
that are easily accomplished by the client. Those activities that
are selected should be listed here. If this diagnosis is in
conjunction with an eating disorder, adjust exercise to
appropriate levels for the client.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the older adult with this diagnosis are the same as those for the adult.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions.
strategies to reduce and cope with disturbance in body image:
Family conference: Discuss meaning of loss or change from
family perspective and from perspective of individual
members. Discuss the effects of the loss on family
relationship roles.
Mutual goal setting: Establish realistic goals, and identify
specic activities for each family member, e.g., assisting with
activities as required or attending support groups as needed.
Communication: Clarify responses to Disturbed Body Image.
Assist the client and family in lifestyle adjustments that may be Rehabilitation is a long-term process. Permanent changes in
required: behavior and family roles require evaluation and support.
Obtaining and providing accurate information regarding
specic Disturbed Body Image and potential for rehabilitation
Maintaining safe environment
Encouraging appropriate self-care without encouraging
dependence or expecting unrealistic independence
Maintaining the treatment plan of the health care
professionals guiding therapy
Altering family roles as required
Consult with or refer to assistive resources as indicated. Utilization of existing services is efcient use of resources.
Rehabilitation therapists and support groups can enhance the
treatment plan.
Copyright 2002 F.A. Davis Company
Interview the patient. Does the patient make during the interview
at least X number of positive body image statements?
Yes No
Record data, e.g., spoke positively Reassess using initial assessment factors.
of visitor from Reach to Recovery;
has chosen prosthesis and believes
no one will be able to tell Ive
had the mastectomy; is doing
exercises; plans to go home
tomorrow and get on with my life.
Record RESOLVED. Delete No Is diagnosis validated?
nursing diagnosis, expected outcome,
target date, and nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Take time to create a trusting relationship and a safe place for A trusting relationship in which the patient feels free to express his
the patient to talk about the things that make him or her feel or her fears will assist the patient to open up.
anxious about death.
Examine your own fear about life, death, and the death Caregivers need to understand their own feelings so they can
experience. Develop a support system for yourself. support the patient and care for him or her nonjudgmentally.
Invite questions; answer honestly the questions that are asked Promotes a trusting relationship.
(but not necessarily the ones that are not asked); give reassurance
where reassurance is possible, and emotional support to grieve
when reassurance is not possible.
Listen when the patient describes his or her pain, and help ease Promotes a trusting relationship.
both the physical and emotional pain.41
Explain that predictions about life expectancy are often wrong, Encourages hope but not false hope.
and support the patient while the situation claries itself.41
(continued)
Copyright 2002 F.A. Davis Company
Child Health
NOTE: Review developmental conceptual considerations with a keen appreciation of unique needs
per each client plus, as applicable, those orders for Adult Health.
ACTIONS/INTERVENTIONS RATIONALES
Assess for all possible contributing factors to include, as A holistic assessment provides the most thorough database for
applicable, the clients verbalization of feelings, family or individualized care.
caregiver perceptions, related family interactions or stressors,
and risk indices, with attempt to identify anxiety to be mild,
moderate, or acute.
Once determined, provide appropriate factual information to There will be a difference in how mild, moderate, or acute anxiety
assist in how best to deal with anxiety. is dealt with.
Determine previous effective coping strategies. Successful coping strategies will assist in establishing possible ways
to augment current needs with modication to offer a sense of
empowerment.
Identify ways to assist the child in coping with appropriate Feelings of empowerment will result when attempts are made to
incorporation of these strategies in daily care, with identication adhere to a regimen that values previously successful coping
of additional coping strategies. strategies on which new strategies may then be more readily
accepted.
Provide a calm atmosphere with limitation of excessive noise, Enhancement of coping is likely when the surrounding atmosphere
interruptions, or numbers of caregivers. does not make more stress.
Provide all health team members updates, and seek information The nurse is in the best position to offer coordination of care.
as needed to coordinate care on a daily basis.
Assist in appropriate involvement of all members of the health Child specialists are most appropriately suited to assist in anxiety
care team, especially the child life specialist, psychiatrist, or reduction strategies.
psychologist.
Encourage the child and family to share thoughts of death-related Creating a sense of safe haven for all fears and thoughts to be
anxiety issues or related feelings on an ongoing basis, with a shared demonstrates a valuing of open communication and the
sensitivity to unexpected potential for same. worth of the individual, thereby reducing anxiety.
Allow for creative modes per developmental preferences such as Age-appropriate expression of anxiety is fostered by preferences of
puppets, video viewing, art, or story telling to share ways to the child per developmental capacity.
deal with death.
Assess for cultural practices to augment care. Individualized sensitivity to culture provides valuing of the person
and the importance he or she places on food, beliefs, or specic
ways to cope.
Identify with the child and family ways to cope with dying and When anxieties are diminished, actual engagement with dying can
meaning of death. be realistically approached.
Offer assistance in obtaining or notifying clergyman, counselors, Anxiety may be further reduced with assistance from those who are
or other supportive personnel as needed. experts in death and dying.
Provide reassurance according to personal family beliefs about Anxiety may be further reduced when the childs fears of being
an afterlife or beliefs of same according to age-appropriate alone or separated can be alleviated, while also supporting valued
concerns of the child. family beliefs.
Womens Health
The interventions for this diagnosis in Womens Health are the same as those given in Adult Health and
Gerontic Health.
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Provide a quiet, nonstimulating environment. (Note these Inappropriate levels of sensory stimuli can contribute to the clients
adaptations to the environment that promote the clients sense of anxiety.
relaxation, i.e., music, scents, lighting, etc.)
Spend [number] minutes per shift talking with the client about Assists the client in establishing the link between the feelings of
concerns and feelings. anxiety and thoughts, which facilitates development of coping
behaviors.43 An expression of feeling helps reduce intense emotion
that can block problem solving.44
After concerns are identied, validate and normalize the Validation of affect can decrease feelings of isolation and assist the
emotional response. client to connect with others, including the family.44
When concerns involve the family and/or support system, Assists the support system in bringing forth their own resources
schedule [number] minutes each day to bring the family and strengths to support one another and problem solve. Decreases
together and facilitate discussion of the issues and concerns. the feeling of isolation in members of the support system who are
coping with the impending death.44
Spend [number] minutes [number] times per day with the Empowers the client, and facilitates growth-promoting change.44
client identifying alternative ways of responding to concerns
that decrease anxiety.
Discuss with the support system their need to provide care, and Provides the support system with a sense of helpfulness and
provide them the necessary information and equipment to control.44
accomplish this at the level they feel comfortable. (Note the
assistance needed to accomplish this care.)
Assess the support systems need for respite, and talk with them Assists the family in coping with guilt about their need to take a
about taking breaks to increase their ability to support the client. break to enhance their coping resources.44
(Note the familys need here.)
Provide the client with information about his or her care. Empowers the client, and decreases concerns about the unknown.
Spend [number] minutes [number] times each day assisting the Shifts physiologic state from sympathetic nervous system arousal
client with a relaxation sequence he or she has identied as to a state of parasympathetic recuperation.37
helpful. This could be deep muscle relaxation, visual imagery,
meditation, or deep breathing exercises. (Note the method
identied by the client here.)
Provide massage for [number] minutes as needed to reduce Promotes physical and psychological relaxation.45
anxiety. (Note the clients preference for massage here.)
Identify support systems in the community, and provide the Provides visual documentation of the importance of follow-up and
client with a connection to these systems before discharge. community support, increasing the likelihood that these referrals
(Note those identied for this client here.) will be utilized.
Gerontic Health
NOTE: Research on the presence of death anxiety in older adults is slowly evolving, with no clear pre-
dictors of which older adults are at risk for experiencing death anxiety. Generally, elders with increased
physical and psychological problems, and decreased ego integrity, are more likely to have death anx-
iety. Which physical and/or psychological problems have an impact on death anxiety are not yet clearly
identied. In addition to selecting interventions from the psychiatric health section, nurses caring for
older adults may nd the following actions to be effective.4650
ACTIONS/INTERVENTIONS RATIONALES
Consult as needed with social services, mental health Enables clients to discuss and address issues that may be
professionals, and/or religious counselors as signs of death contributing to distress.
anxiety are noted.
Monitor older adults for signs of decreased ego integrity, such Decreased ego integrity is a contributor to death anxiety noted in
as statements of regret related to past life experiences, older adults.
unresolved relational problems, and expressions of despair.
Assist and encourage the older adult in life review process. Provides opportunity to review prior successes, effective and
ineffective coping strategies, personal strengths and sense of life
satisfaction, and psychological well-being.
Refer the client to hospice services if the client meets admission The hospice care team is prepared to address needs surrounding
criteria for hospice care. death and dying.
Copyright 2002 F.A. Davis Company
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Manage the clients pain and other troubling symptoms, such Physical symptoms often contribute to anxiety.
as nausea.
Encourage the family to become involved in the care of the A sense of purpose and usefulness can replace anxiety.
client as much as they are able.
Help the client to talk about his or her anxiety and its source. Makes the client, the nurse, and the family more aware of issues
that need discussing or problems that need to be addressed.
Listen to client and family concerns, and answer all questions Understanding helps promote a sense of control and order.
truthfully. Tell the client and family as much as you can to
decrease the number of surprises they may experience with
the dying process.51
Acknowledge all fears, feelings, and perceived threats as valid to All client fears are valid to the client, whether they are realistic
the client. or not.
Reassure the client that even though the dying process cannot Fear of abandonment is an almost universal fear of dying persons.51
be stopped, someone will be with them and they will not be left
alone. Then ensure that a family member or caregiver is with
the patient at all times.
Administer anxiolytics as ordered, and educate the family or Promotes sense of well-being.
caregivers about prescribed medications, their effects, side
effects, and scheduling.51
Copyright 2002 F.A. Davis Company
Death Anxiety
Yes No
No Finished
Copyright 2002 F.A. Davis Company
c. Impulsiveness
Fear d. Narrowed focus on it (i.e., the focus of the fear)
DEFINITION 5. Physiologic
a. Increased pulse
Response to perceived threat that is consciously recognized as b. Anorexia
danger.33 c. Nausea
d. Vomiting
NANDA TAXONOMY: DOMAIN 9COPING/STRESS e. Diarrhea
TOLERANCE; CLASS 2COPING RESPONSES f. Muscle tightness
g. Fatigue
NIC: DOMAIN 3BEHAVIORAL; CLASS RCOPING h. Increased respiratory rate and shortness of breath
ASSISTANCE i. Pallor
j. Increased perspiration
NOC: DOMAIN IIIPSYCHOSOCIAL HEALTH; k. Increased systolic blood pressure
CLASS OSELF-CONTROL l. Pupil dilation
m. Dry mouth
DEFINING CHARACTERISTICS33
1. Self-reported symptoms of: RELATED FACTORS33
a. Apprehension
b. Increased tension 1. Natural or innate origin, for example, sudden noise, height,
c. Decreased self-assurance pain, or loss of physical support
2. Self-reported feelings of: 2. Learned response, for example, conditioning or modeling from
a. Excitement or identication with others
b. Scared 3. Separation from support system in a potentially threatening sit-
c. Jitteriness uation, for example, hospitalizations or procedures
d. Dread 4. Unfamiliarity with environment experience(s)
e. Alarm 5. Language barriers
f. Terror 6. Sensory impairment
g. Panic 7. Phobic stimulus
3. Cognitive 8. Innate releasers (neurotransmitters)
a. Identies object of fear
b. Stimulus believed to be a threat RELATED CLINICAL CONCERNS
c. Diminished productivity, problem solving ability, learning
ability 1. Any hospitalization
4. Behaviors 2. Any threat to loss of a body part, loss of functioning, or loss of
a. Increased alertness life
b. Avoidance or attack behaviors
FEAR 477
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to correct any sensory decits. Inability to correctly sense and perceive stimuli may increase fear.
Maintain calm, safe environment throughout the A nonthreatening environment decreases fear.
hospitalization:
Use frequent reassurance.
Touch the patient frequently.
Have someone remain with the patient.
Administer antianxiety medications as ordered. Observe and Determines effectiveness of medication, and allows changing of
record response to medication within 30 min after medication as needed.
administration.
Monitor, at least every 4 h while awake: Determines physiologic changes due to fear. Assists in determining
Vital signs whether physiologic changes are causing pathology.
Degree of confusion
Degree of reality orientation
Provide information to the patient in both written and verbal Fear interferes with interpretation of verbal input. Written forms
forms. provide reinforcement and assist the patient to focus and attend to
activities.
Sit down and visit with the patient at least 1520 min every 4 h Provides an opportunity for the patient to ask questions and
while awake: verbalize fears.
Listen carefully.
Support positive coping.
Give clear, concise, straightforward information.
Assist the patient to increase development of decision-making Helps the patient practice, in a nonthreatening environment, the
skills: problem-solving process. Increases feeling of personal control of
Review decision-making process with the patient. situation.
Provide opportunity for decision making regarding care.
Assist the patient in developing a list of potential solutions
to the threatening situation.
Review the developed list of solutions with the patient, and
solution.
situation.
making.
Collaborate with psychiatric nurse clinician regarding care (see Collaboration promotes a holistic and thorough plan of care.
Psychiatric Health nursing actions).
Teach the patient and signicant others: Gives additional methods that are successful in dealing with fear.
Use of progressive relaxation and guided imagery
Use of exercise balanced with rest
Proper food and uid intake
Refer to appropriate community resources for assistance. Provides support resources for follow-up on plan after discharge
from the hospital.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Offer brief interactions that assist the patient and family with Brief explanations and factual information serve to empower the
orientation, e.g., hospital unit, procedures, and aspects of care. patient and family as the unknown is made known. The patient
and family can then focus on dealing with the identied fear
rather than dealing with added fears.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
NOTE: Phobias affect approximately 2 to 3 percent of the adult population, and 80 percent of the af-
fected group are female. The most common phobias among women are agoraphobia, fear of animals,
and fear of social situations.52,53
ACTIONS/INTERVENTIONS RATIONALES
Obtain a detailed history of the patients fears: Provides essential database for planning appropriate interventions.
Encourage the patient to discuss signs and symptoms or
precipitating event.
Ascertain how often problem occurs.
Have the patient describe her reaction.
Identify coping mechanisms that have previously helped.
Identify those factors or coping mechanisms that do not help.
DOMESTIC VIOLENCE
Provide a nonjudgmental, safe environment for the patient to
verbalize her fears. In childbirth and parenting classes, discuss
family violence. Obtain a good history that can identify
high-risk families. Be alert to subtle clues in the patients history
or physical examination that hint at physical abuse.
Patiently explain all procedures and their purpose to the patient
before performing them. Be aware that procedures in labor and
delivery can trigger unpleasant fears and anxieties in the patient,
with possible ashbacks to an abusive situation or rape. Perform
necessary procedures as quickly as possible and with empathy,
allowing the patient to direct as much of the care as possible.
Encourage the patient to verbalize her fears and verbally relive
the birth experience in a nonjudgmental environment.
(continued)
Copyright 2002 F.A. Davis Company
FEAR 479
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Inform patients of services and shelters for the battered woman. It is important to provide information about resources to these
Post telephone numbers in conspicuous places. Post telephone women in an unobtrusive manner, so they can access the resources
numbers in womens bathroom (unavailable to men, so they when they are ready.
cannot see partner getting number). Tell women to memorize
number, never write it down.
BIRTHING PROCESS
Provide a comfortable, nonjudging atmosphere to encourage Assists in decreasing fear through promotion of verbalization.
the patient and her signicant other to verbalize their fears of:
The unknown
Safety for herself and her baby
Pain during the birthing process
Mutilation during the birthing process
Losing control during the birthing process
Refer the patient to appropriate support groups for information: Provides effective use of existing resources and long-range support.
Childbirth education classes in the community
Schools of nursing (students in obstetrics who have
follow-through of families of pregnant women)
Monitor the patients level of condence using prepared Use of relaxation techniques and provision of information
childbirth techniques during labor: regarding progress facilitate the labor process by easing anxiety
Encourage use of relaxation and prepared childbirth and promoting comfort.38
techniques during labor.
Provide ongoing and accurate information, during the labor
other.
Provide continuity of care by remaining with and providing Encourages involvement in process, which enhances coping.
comfort for the laboring woman throughout the birthing
process:
Provide clear answers to the patients questions.
Keep the patient informed of her progress in the birthing
process.
Provide the patient and signicant others with as many
opportunities as possible to make decisions about her care
during the birthing process.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Provide a quiet, nonstimulating environment for the client. This Inappropriate levels of environmental stimuli can increase
would include removing persons and objects that the person disorientation and confusion. Manipulation of the environment
perceives as threatening. If the person is experiencing a thought can eliminate the fear response.54
disorder with delusions and hallucinations, attention should be
paid to the details of the environment that could be misinterpreted.
At times a same-sex caregiver can increase fear in the client.
Obtain the clients understanding of the threat. Facilitates the development of interventions that directly address the
clients concerns.
Provide a one-to-one relationship for the client with a member Promotes a trusting relationship, and enhances the clients
of the nursing staff. This should be maintained until the self-esteem.
symptoms return to normal levels.
Provide clear answers to the clients questions. Inappropriate amounts of sensory stimuli can increase the clients
confusion and disorganization.
Carry on conversations in the clients presence or vision in a Meets safety needs of the client by eliminating stimuli that could
voice that the client can hear. be misinterpreted in a personalized manner.
Inform the client of plans related to care before the plans are Promotes the clients sense of control, and enhances self-esteem.
implemented. If possible, discuss these with the client (e.g., if
it is necessary to move the client to another room or institution,
the client should be informed of this change before it takes
place).
(continued)
Copyright 2002 F.A. Davis Company
see that you are very upset. I can understand how those
concerns.
situation. The client tells you that you must be angry with
him or her because of the look you had on your face while
Provide the client with as many opportunities as possible to Promotes the clients sense of control, and enhances self-esteem.
make decisions about his or her care and current situation.
Assist the client in developing a list of potential solutions to the Teaches the client problem-solving skills, while promoting the
threatening situation. clients sense of control and strengths.
Review developed list of solutions with the client, and assist Facilitates the clients decision-making process.
him or her in evaluating the benets and costs of each solution.
Rehearse with the client, if necessary, the solution selected, or Behavioral rehearsal helps facilitate the clients learning new skills
have the client practice a new response to the threatening through the use of feedback and modeling by the nurse.55
situation.
Provide positive feedback to the client about efforts to resolve Positive feedback encourages behavior and enhances self-esteem.
the threatening situation.
Assist the client in developing alternative outlets for the feelings Planned coping strategies facilitates the enactment of new
generated by the threatening situation, and provide the behaviors when the client is experiencing stress.
opportunity for the use of these outlets. These would be noted
in the chart so other staff members would be aware of them and
could encourage their use when they notice the clients
discomfort increasing.
Assist the client in identifying early behavioral cues that indicate Early recognition and intervention enhances the opportunities for
fear or that he or she is entering a fearful situation. new coping behaviors to be effective.
Encourage the client in alternative coping strategies developed by: Promotes the clients perception of control. Positive reinforcement
Providing the necessary environment encourages behavior.
Providing the appropriate equipment
Spending time with the client doing the activity
Providing positive reinforcement for the use of the strategy
(this could be verbal as well as with special privileges)
(continued)
Copyright 2002 F.A. Davis Company
FEAR 481
(continued)
ACTIONS/INTERVENTIONS RATIONALES
If fear is related to a specic object or situation, teach the client The relaxation response inhibits the activation of the autonomic
to use deep muscle relaxation, and then teach this along nervous systems ght-or-ight response.
with progressively real mental images of the threatening
situation. This is for those situations that will not cause the
client harm if he or she is approached, such as riding in
elevators. This could also include other methods of relaxation
such as music, deep breathing, thought stopping, fantasy,
assertiveness training, audiotapes with relaxation images or
sequences, yoga, hypnosis, and meditation.
Explore ways to increase the clients feeling of control in
threatening situation; e.g., a fear of elevators could be altered
by the client only riding in elevators with emergency telephones
and only riding when he or she could stand near the telephone.
The fear may also indicate that the client is feeling out of control
in an unrelated area of his or her life. If this is suspected, this
should be explored and ways of increasing control should be
explored; e.g., a womans fear of driving could indicate that she
feels out of control in her marriage, and increased assertive
behavior with her husband removes the fear.
When the client shows signs and symptoms of fear (note those Shifts physiologic state from sympathetic nervous system arousal
signs and symptoms unique to this client here), talk him or her to a state of parasympathetic recuperation.37 Behavioral rehearsal
through the coping and/or relaxation strategies that have been helps facilitate mastery of new behavior through the use of feedback
identied as useful to him or her. Note the clients specic and modeling by the nurse.35 Promotes sense of control.43
coping strategies to be used here. This may include removing Contextual stimuli can elicit the fear response.54
the client from the fear-producing context.
Provide positive reinforcement for the clients implementation Positive reinforcement encourages behavior.
of the new coping behaviors. Note those things that are to be
used to reinforce this client here.
If the method to increase control involves interactions with the Promotes the clients sense of control, and enhances self-esteem.
health care team, these should be noted in specic terms on the
clients chart.
Assist the client in developing strategies to be used in the Behavioral rehearsal provides opportunities for feedback and
community after discharge, and role-play various situations modeling from the nurse.
with the client for at least 1 h for at least 2 days.
Collaborate with other members of the health care team to GABA agonists inhibit the amygdala, which is the location of the
provide clients with pharmacologic agents to be administered fear response.54
prior to exposure to a context that elicits fear.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient in identifying the source of feare.g., pain, Identifying the source of fear enables the patient to develop a
death, or loss of functionby scheduling at least 30 min twice specic plan of action to reduce the fear.
a day at [times] to confer with the patient about fear.
Assist the patient in determining what resources are available to Knowledge and use of appropriate resources aid in reducing
enhance his or her coping skills. fear-provoking experiences by increasing the patients inventory
of skills to deal with fear.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Ask the client to describe the precipitating event. Assists the nurse in understanding the clients perception of the fear.
Determine the clients perception of the fear. Assists the nurse in understanding the clients perception of the fear.
Assess sources of support, resources, and usual coping methods. Assists the nurse in understanding the clients perception of the fear.
Identify which coping strategies that the client has previously Growth can occur if effective skills are applied in future situations.
used have been effective and which have not. Discuss ways that
effective strategies can be used to cope with future fearful
events.
(continued)
Copyright 2002 F.A. Davis Company
FEAR 483
Fear
Yes No
Record data, e.g., has identified Reassess using initial assessment factors.
primary source of fear of flying
as having no control over situation.
Record RESOLVED (may wish to
use CONTINUE until patient
has identified and successfully
implemented coping mechanisms).
Delete nursing diagnosis, No Is diagnosis validated?
expected outcome, target date,
and nursing actions
No Finished
Copyright 2002 F.A. Davis Company
5. Decreased appetite
Hopelessness 6. Decreased response to stimuli
DEFINITION 7. Increased or decreased sleep
8. Lack of initiative
A subjective state in which an individual sees limited or no alterna- 9. Lack of involvement in care or passivity allowing care
tives or personal choices available and is unable to mobilize energy 10. Shrugging in response to speaker
on own behalf.33 11. Turning away from speaker
HOPELESSNESS 485
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Establish a therapeutic and trusting relationship with the patient Promotes a safe environment to encourage the patient and/or
and family by actively listening, being nonjudgmental, sitting family to verbalize concerns. Promotes empathetic environment.
with the patient, touching (as welcomed by the patient), etc.
Identify other primary nursing needs, and deal with these as Inattention to basic needs increases feelings of hopelessness and
needed. of being of no value.
Support the patents efforts at objectively describing feelings of Assists the patient in releasing tension. Allows the patient to
hopelessness when interacting with the patient. validate reality.
Assist the patient to nd alternatives to feelings of hopelessness Validates reality and encourages use of coping techniques. Points
as the patient expresses them. out the variety of solutions available.
Assist the patient to engage in social interaction at least once Provides diversion, and decreases sense of isolation.
per shift.
As health status permits, increase activity level. Have the patient Encourages the patient to regain control in small increments.
participate in self-care management, adding an activity such as Decreases the idea that the personal self is responsible for the
washing face one day, washing face and arms the next day, etc., situation.
or have the patient walk to bathroom rst day and ambulate
30 ft down the hall the next day.
Encourage food and uid intake to at least 1500 calories per Hopelessness may prompt unhealthy eating patterns.
day and at least 2000 mL per day.
Moderate sleep-wake cycles: Maintains diurnal rhythm and promotes rest.
Provide diversional activities during the day.
Do not let the patient take naps during the day.
Provide massage at bedtime.
Darken the room, but provide a night light for sleep.
Give sleep medication as ordered, and monitor effects.
Encourage active participation in activities of daily living. Allow Helps restore sense of being in control.
for preferences in day-to-day decisions, e.g., establishing a bath
time. Provide explanations and appropriate teaching for
procedures and treatments.
Refer to psychiatric nurse clinician as needed (see Psychiatric Collaboration promotes a more holistic and complete plan of care.
Health nursing actions).
Identify religious, cultural, or community support groups prior Support groups can provide advocacy for the patient and
to discharge. Provide appointments for follow-up. continued monitoring and support of the patient after discharge
from the hospital.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for the etiologic components contributing to Provides database that results in a more accurate and complete
hopelessness pattern. plan of care.
Encourage the patient and family to verbalize feelings about Verbalization helps reduce anxiety and assigns value to the
current status with 30 min set aside each shift at [times] for this patients concerns. Allows ongoing assessment.
purpose.
Assist the patient and family to explore growth potential Opportunity for growth may be overlooked in times of crisis.
afforded by this specic experience.
Allow opportunities for the child to play out feelings under Play and the acting out of feelings provide insight into coping and
appropriate supervision: perceptions of the child in a noninvasive mode. Provides valuable
Play with dolls for toddler data to monitor feelings, concerns, etc.
Art and puppets for preschooler
Peer discussions for adolescents
Copyright 2002 F.A. Davis Company
Womens Health
NOTE: The following nursing actions are for the couple (husband or wife) who have been unable to
conceive a child. See Chapter 10 for detailed information on infertility. Provide a nonjudgmental at-
mosphere to allow the infertile couple to express their feelings such as anger, denial, inadequacy, guilt,
depression, or grief.
ACTIONS/INTERVENTIONS RATIONALES
INFERTILITY
Support and allow the couple to work through grieving process Provision of support for and encouragement of discussion
for loss of fertility, for loss of children, for loss of idealized regarding emotions allows the couple to begin to deal with
lifestyle, and for the loss of feminine life experiences such as emotions and lays groundwork for future decision making.38
pregnancy, birth, and breastfeeding.
Encourage the couple to talk honestly with one another about
feelings.
Encourage the couple to seek professional help if necessary to
deal with feelings related to sexual relationship, conicts,
anxieties, parenting, and coping mechanisms used for dealing
with loss of fertility (their expectations, relatives expectations,
and societys expectations).
Be alert for signs of depression, anger, frustration, and Allows early intervention and avoidance of complications.
impending crisis.
Provide the infertile couple with accurate information on Provides informational support for decision making.
adoption and living without children.
POSTPARTUM DEPRESSION
NOTE: The majority of patients who experience hopelessness
leading to postpartum depression have been found to have
underlying psychiatric disorders or life experiences other than
pregnancy that accounted for the depression.56
Provide factual information to the patient and partner on Give the patient and partner realistic guidelines for when they
postpartum depression. Describe difference between might need to seek professional help for depression beyond
baby blues and depression. Identify potential psychosocial baby blues.
triggers in the patients environment that could lead to
postpartum depression, such as:
Feelings of ambivalence
Feelings of inadequacy
Marital discord
Guilt and irritability
DOMESTIC VIOLENCE57
Provide nonjudgmental atmosphere that allows the patient to
express anger, fears, and feelings of hopelessness. Refer the
patient to appropriate agency for assistance to nd shelter and
psychological counseling. Assist the patient in developing a plan
of action in the event of a situation that could threaten her or
her childrens safety.
Place telephone numbers for assistance in womens bathroom Provides resources and information to patients without putting
and other places women can see and memorize it without fear them or their children in further danger.
of reprisal from partner.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor health care teams interactions with the client for Negative attitudes from staff can be communicated to the client.
behavior (verbal and nonverbal) that would encourage the
client not to be hopeful. If situations are identied, they should
be noted here, and the team should discuss alternative ways of
behaving in the situation. The actions that are determined to be
needed to support the clients hope should be noted on the
clients chart.
(continued)
Copyright 2002 F.A. Davis Company
HOPELESSNESS 487
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Sit with the client [number] times per day at [times] for 30 min Promotes positive orientation by assisting the client in
to discuss feelings and perceptions the client has about the remembering past successes and important aspects of life that
identied situation. These times should also include discussions make it important that they succeed this time.58
about the clients signicant others, times the client has enjoyed
with these persons, the projects or activities the client was
planning with or for these persons that have not been
accomplished, the clients values and beliefs about health and
illness, and the attitudes about the current situation.
Identify with the clients signicant others times that they can talk Negative expectations from the support system can be
with the staff about the current situation. Themes that should communicated to the client.
be explored during this interaction should be their thoughts and
feelings about the current situation, ways in which they can
support the client, the importance of their support for the client,
questions they may have about the clients situation, and possible
outcomes. (Note the time for this interaction here as well as the
name of the person who will be talking with the signicant others.)
Note times when signicant others will be visiting, and schedule Assists the client in maintaining connections with the support
this time so there will be a private time for them to interact with systems, and increases awareness of contributions the client has
the client. (Note these times here, and designate those times that made in the past and can make in the future to this system.
are scheduled as private visitation times.) Inform the client and
signicant others of those places on the unit where they can
have privacy to visit.
Identify with the client preferences for daily routine, and place Promotes the clients sense of control.
this information on the chart to be implemented by the staff. It
is vital to this client to have the information shared with all staff
so that it will not appear that the time spent in providing
information was wasted.
Provide answers to questions in an open, direct manner. Promotes the clients sense of control, while building a trusting
relationship.
Provide information on all procedures at a time when the client
can ask questions and think about the situation.
Allow the client to participate in decision making at the level to Promotes the clients sense of control in a manner that increases
which he or she is capable of doing so. The client who has never the opportunities for success. This success serves as positive
made an independent decision would be overwhelmed by the reinforcement.
complexity of the decisions made daily by the corporation
executive. If necessary, offer decision situations in portions that
the client can master successfully (the amount of information
that the client can handle should be noted here as well as a list
of decisions the client has been presented with).
Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while enhancing
decisions made. Those things that are reinforcing for this client self-esteem.
should be listed here along with the reward system that has
been established with the client; e.g., play one game of cards
with the client when a decision about ways to cope with a
specic problem has been made.
Provide verbal social reinforcements along with behavioral Promotes the development of a trusting relationship.
reinforcements.
Keep promises (specic promises should be listed on the chart
so that all staff will be aware of this information).
Accept the clients decision if the decision was given to the Promotes the clients sense of control, while enhancing self-esteem.
client to make. These decisions should be noted on the chart.
Provide ongoing feedback to the client on progress. Provides positive reinforcement for accomplishments.
Spend 30 min a day talking with the client about current coping Interaction with the nurse can provide positive reinforcement.
strategies and exploring alternative coping methods. Note time Behavioral rehearsal provides opportunities for feedback and
for this discussion here as well as the person responsible for this modeling of new behaviors from the nurse.
interaction. When alternative coping styles have been identied,
this time should be used to assist the client with necessary
practice. The alternative styles that the client has selected
should be noted on the chart, and the staff should assist the
client in implementing the strategy when appropriate. These
could include deep muscle relaxation, visual imagery, prayer,
or talking about alternative ways of coping with stressful events.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the older adult with this diagnosis are the same as for the adult health and men-
tal health patient.
Copyright 2002 F.A. Davis Company
HOPELESSNESS 489
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to the hopelessness, e.g., Provides database for earlier recognition and intervention.
psychological, social, economic, spiritual, or environmental
factors.
Involve the client and family in planning, implementing, and Claries roles. Personal involvement in planning, etc. Increases the
promoting reduction or elimination of hopelessness: likelihood of success in resolving problem.
Family conference: To identify and discuss factors
contributing to hopelessness
member identied
Communication
Assist the client and family in making lifestyle adjustments that Lifestyle changes require signicant behavior change. Self-
may be required: evaluation and support can assist in ensuring that changes are
Use relaxation techniques: Yoga, biofeedback, hypnosis, not transient.
breathing techniques, or imagery.
Provide assertiveness training.
Provide opportunities for individual to exert control over
situation. Give choice when possible; support and encourage
self-care efforts.
Consult with or refer to assistive resources as indicated. Effective use of existing community resources.
Copyright 2002 F.A. Davis Company
Hopelessness
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., has attended Reassess using initial assessment factors.
continuing education course
on assertiveness; has appointment
at pain clinic; has redistributed
workload. Record RESOLVED.
Delete nursing diagnosis, expected
outcome, target date, and nursing
actions. No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
RISK FACTORS33
1. Affectional deprivation EXPECTED OUTCOME
2. Social isolation
3. Cathectic deprivation Will implement a plan to reduce risk for loneliness by [date].
4. Physical isolation
TARGET DATES
RELATED CLINICAL CONCERNS This is a fairly long term diagnosis and will require much support
1. Any chronic illness to offset. Therefore, an appropriate initial target date would be 10
2. AIDS to 14 days.
3. Mental health diagnoses
4. Cancer
5. Any condition causing impaired mobility
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for symptoms of loneliness. Symptoms are often hidden Helps develop a database on which planning can take place.
or disguised: expressed through withdrawal, depression, or a
profound sense of hopelessness; or vague physical symptoms
such as headache; hostility; anger toward those around him or
her or with life in general. Prolonged internal conicts may
manifest as inappropriate coping, such as overeating, excessive
drinking or smoking, drug use, or other self-destructive behaviors.
Note signicant other(s) who visit or call the patient. Assess the The separation from signicant other(s) and from previously
degree of support and availability of signicant other(s). established support systems may contribute to loneliness.59
Help identify beliefs, values, hobbies, and areas of interest.
Encourage him or her to join a group with common interests. The older adult is not as easily accepted into social interactions or
Age-related groups may be helpful for the older patient. Group relationships because of social bias toward the aged.60 The use of
process should focus on realistic, relevant issues. groups and group process has been most successful in treating
loneliness.61
Encourage the patient to be involved in his or her care. Involving the patient in care directly inuences movement away
from loneliness.62 It also reduces feelings of powerlessness and
fosters interest in self-care.59
Discuss body image, hygiene, visible signs of illness, function The person becomes isolated either because of rejection of others
loss, and his or her perceptions of how he or she can change or because he or she seeks little interaction as a result of the
things. self-consciousness he or she feels.60 Negative ways of viewing self
arising from physical or emotional disabilities can confound
problems, lower self-esteem, and lead to loneliness.61
Assist the patient to nd alternate support systems, even short, Patients perceive that nurses can offer psychological support with
quality interactions with the nurse. even short visits.61
Assign a primary nurse to care for the patient. Provides consistency in care.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
Same as for Adult Health, with attention to developmentally appropriate approach for all interventions.
When other diagnoses (e.g., Grief or Loss, Parent-Infant Separation, Coping), also contribute to this pat-
tern, seek follow-up with concurrent plan for loneliness as well.
ACTIONS/INTERVENTIONS RATIONALES
If anaclitic depression is to be considered, stage appropriately In separation anxiety, the infant or child may have different needs,
for current/ongoing status, i.e., protest, despair, or withdrawal. but all will help direct caregivers to support client regain bonding
with others.
Determine best how to support the infant, child, or adolescent Holistic planning according to realistic capacity of the infant, child,
coping with loneliness as applicable: or adolescent will provide appropriate chance to reestablish sense
Play therapy or counseling of belonging.
Consideration of developmental capacity
Access to activities within the local community
Assessment of physical or emotional readiness, for both the
individual and the family
Allowance for regression due to illness
Support services, foster grandparents, volunteers, Child
Protective Services (CPS), or college interest groups
Involve all who have input in establishing consistent long-term Often underlying dynamics may require long-range planning.
goals.
When necessary, advocate for the infant or child. Loneliness may be related to abuse on part of parents and must be
considered appropriately.
Ensure allowance for counseling for appropriate valuing of Loneliness will undermine family dynamics if left unrecognized.
family needs.
Offer 30 min each shift for the client or parents to ventilate Frequent verbalization will offer cues to suggest insight into how
feelings about loneliness. loneliness is being perceived and provide basis for most
appropriate treatment.
Womens Health
NOTE: The heath care provider will see this diagnosis in many more female clients than in male clients
as a result of women outliving men. This is one of the most frequent diagnoses in geriatric women.
ACTIONS/INTERVENTIONS RATIONALES
POST PARTUM
Provide the patient with access to support by providing
telephone number and name of available support person she
can call with questions.
Encourage new parents to attend parenting support groups and Provides new parents support and guidance during the rst days
participate in parent education programs in the acute care of the postpartum period, and assists in the transition to
setting and in the community after discharge. Suggest to parents: parenthood.
YWCA
Churches
Neighborhood groups
Friends who have had babies
State-funded follow-up programs
SINGLE PARENTS
Assist the new mother to develop a plan for coordinating
activities of daily living with the new infant.
Assist the patient in identifying available resources:
Family
Signicant others
Community agencies
Peer groups
Copyright 2002 F.A. Davis Company
resources.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Spend [number] minutes [number] times a day discussing with Assists in understanding the clients worldview, which facilitates
the client his or her perception of the source of the loneliness, the development of client-specic interventions. Increases the
and have them discuss how they have tried to resolve the clients sense of involvement and empowerment.63
situation.
Have the client list those persons in the environment who are Facilitates the clients reality testing of perception of being alone.
considered family, friends, and acquaintances. Then have the
client note how many interactions per week occur with each
person. Have the client identify what interferes with feeling
connected with these persons. Note here the person
responsible and schedule for this interaction.
When contributing factors have been identied, develop a plan Facilitates the development of alternative coping behaviors, and
to alter them. This could include: improves social skills, which improves role performance and social
Assertiveness training condence.
Role-playing difcult situations
Teaching the client relaxation techniques to reduce anxiety in
social situations
Providing the client with aids to compensate for sensory
decits
Providing the client with special clothing or prosthetic
devices to enhance physical appearance
Teaching the client personal hygiene necessary to maintain
aesthetic appearance (ostomy care, incontinence care, or
wound care)
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
See actions and interventions under Psychiatric Health. The older adult who is experiencing losses asso-
ciated with aging, such as loss of a spouse, decline in physical health, and changes in role, is especially
vulnerable to loneliness.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family to identify and prevent risk factors Early recognition and intervention can interrupt development of
of loneliness: loneliness.
Physical and social isolation
Deprivation
A terminal diagnosis can result in less outside interaction. If Reestablishes previous social contacts.
friends stop visiting, assist the family and client to understand
possible reasons:
It is difcult for others to face their own mortality.
Others may fear that the client is too sick for visitors.
The client and family should speak frankly with friends
and family about these issues and their wishes regarding
visitors.
Assist the client and family in lifestyle adjustments that may be Home-based care requires involvement of the family. Loneliness
necessary: can disrupt family schedules and role relationships. Adjustments in
Develop a plan for increased involvement; e.g., begin with family activities and roles may be required.
social contacts that are least threatening.
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., inability of the client appropriate assistance as need arises.
or family to care for the client.
Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the
family member with loneliness.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has joined Reassess using initial assessment factors.
senior citizens dance club and
local chapter of AARP. Works
one day/wk as volunteer
at childrens library.
Record RESOLVED. Delete
nursing diagnosis, expected
outcome, target date, and No Is diagnosis validated?
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
NOTE: Should the patient develop this nursing diagnosis on an adult health care unit, referral should
be made immediately to a mental health nurse clinician. See nursing actions under Psychiatric Health.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributing factors that might predispose the Provides the database needed to more accurately and completely
development of Disturbed Personal Identity: plan care.
Risk indicating an altered maternal-infant attachment, e.g.,
parents overprotection or ignoring of the infant
Altered development norms related to independent
functioning, e.g., following commands (Check for organic
or sensory-perceptual decits.)
Preference for solitary play
Display of self-stimulation and/or self-mutilation
behaviors
History of altered identity problems in the family
Provide basic care for other needs with prioritization for safety In anticipatory safety planning, standards must be in accord with
needs. Close observation is mandatory. both the known as well as the unknown self-injury potential of the
patient.
Administer medications as ordered, with attention to hydration The patient is prone to dehydration and malnutrition due to
and nutritional concerns. inability to rely on usual thirst or appetite regulators.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
The nursing actions for the woman with this nursing diagnosis would be the same as those for the men-
tal health client. Also see Risk for Loneliness and Anxiety.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Assign primary care nurse to establish trusting nurse-client Establishes boundaries so changes can be immediately processed.63
relationship.
Provide the client with information about unit structure, Assists the client in establishing clear interpersonal boundaries.
policies, expectations, and requirements.
Provide a quiet, nonstimulating environment. Inappropriate levels of sensory stimuli can increase confusion and
sense of disorganization.
Provide frequent interactions that assist the client with Promotes the development of a trusting relationship within the
orientation. clients attention span.
Verbal information should be provided in simple, brief Interactions with others also assist in reestablishing weak ego
sentences. boundaries.
Sit with the client [number] minutes [number] times per day at Promotes the development of a trusting relationship. Provides
[times] to provide the client with an opportunity to discuss positive reinforcement for the client, meeting needs in a more
feelings and thoughts. constructive way.
Provide the client with honest, direct feedback in all interactions. Promotes the development of a trusting relationship.
Utilize constructive confrontation if necessary, to include: Assists the client in establishing ego boundaries, while supporting
I statements self-esteem.
Relationship statements that reect nurses reaction to the
interaction
Responses that will assist the client in understanding, such
as paraphrasing and validation of perceptions
Develop, with the health team, a clear set of boundaries and Firm limits facilitate the clients focusing on feelings rather than
expectations and the consequences for inappropriate behaviors. moving away from them.65 Prevents staff splits, which are
Schedule frequent team meetings to review the clients behavior detrimental to clients who have identity and splitting problems.65
and to make revisions in care. Note times of meetings here.
Discuss with the client the source of the threat. Assists the client in developing more adaptive coping behaviors.
Develop with the client alternative coping strategies. Those Promotes the clients sense of control and positive expectational set
activities, items, or verbal responses that are rewarding for the by providing a concrete plan for responding to stressful situations.
client should be listed here.
When the client is presented with a threat, assist with Behavioral rehearsal provides opportunities for feedback and
progressing through one of the alternative coping methods, or modeling from the nurse.
practice with the client the alternative coping methods [number]
minutes twice a day.
Develop achievable goals with the client. (The goals that are Goal achievement enhances self-esteem and promotes a positive
appropriate for this client should be listed here.) expectational set, which motivates the client to move on to more
complex goals and behavior change.
As the client masters the rst set of goals, develop increasingly Moves the client toward health goals in a manner that promotes
complex goals and problems. self-esteem.
Provide positive reinforcement for accomplishments at any level. Positive reinforcement encourages behavior while enhancing
(Those activities, items, or verbal responses that are rewarding self-esteem.
for the client should be listed here.)
Do not argue with the client who is experiencing an alteration Arguing with the belief interferes with the development of a
in thought process (refer to Chap. 7 for nursing actions related trusting relationship and does not serve to change the perceptions.
to Disturbed Thought Process).
Monitor the clients mental status before attempting learning or Alterations in mental status can interfere with the clients ability to
confrontation. If the client is disoriented, orient to reality as process information, and teaching at this point could increase
needed. stimuli to a level that would only increase the clients confusion
and disorganization.
(continued)
Copyright 2002 F.A. Davis Company
Remind alters they are part of the host personality. Discourages dissociation, while encouraging integration.
Discuss the feelings that have been dissociated, rather than Encourages integration.
Gerontic Health
NOTE: In the event the patient is unable to distinguish between self and nonself, it is necessary to con-
tact a mental health clinician to further assess and devise the plan of care. Please see Psychiatric Health
nursing actions.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions.
strategies to reduce and cope with disturbance in personal
identity:
Family conference: Discuss feelings related to disturbance in
personal identity of the client.
Mutual goal setting: Establish realistic goals, and identify
feedback.
Assist the client and family in lifestyle adjustments that may Disturbed Personal identity can be a chronic condition that alters
be required: family relationships. Permanent changes in behavior and family
Maintaining a safe environment roles require evaluation and support.
Altering roles as necessary
Maintaining the treatment plan of the health care
professionals guiding therapy
Consult with or refer to assistive resources as indicated. Utilization of existing services is efcient use of resources.
Psychiatric nurse clinicians and support groups can enhance the
treatment plan.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., easily lists Reassess using initial assessment factors.
five characteristics of self with
100% accuracy; also accurately
lists items that are nonself.
Record RESOLVED. Delete
nursing diagnosis, expected
outcome, target date, and
nursing actions. No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
ADDITIONAL INFORMATION tually exercising power to motivate other parts of the system to act
in certain ways. Understanding this conceptual model provides the
The paradox of the metaphor of power has been presented in the client with an opportunity to know how ones behavior affects the
literature. Systems theorists and cyberneticians have presented the situation and provides nurses with an opportunity to understand
most useful information when one is planning intervention strate- their reactions to and feelings toward the client with the diagnosis
gies. Keeney66 presents a summary of the debate over the power of Powerlessness. If the power metaphor is not accepted, this
metaphor. In sum, most cyberneticians nd this to be an invalid affects the concept of internal versus external locus of control.
metaphor when discussing systems of interaction. The process of The concepts of internal and external loci of control become
a system involves mutual interactions, and within a system each metaphors for how a person perceives personal inuence within
member exerts inuence over the other members. Therefore, the an interactional system. Persons with an external locus of control
individual who acts as if he or she is powerless is exerting power do not understand their inuence on the system, whereas persons
over the other parts of the system to act in a manner that would with an internal locus of control have an understanding of per-
increase this lost personal power. The powerless one is then ac- sonal inuence.
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Plan care with the patient on a daily basis: Allows the patient to have control over environment and care
Likes and dislikes attributes. Imparts to the patient a sense of power.
Where he or she wants personal items placed
Routines, to extent possible, according to the patients own
pace and schedule
Involve signicant others in care. Promotes involvement in care and advocacy for the patient, thus
empowering both the patient and signicant others.
Monitor, at least once per shift: Changes in these signs may signal dysfunctions in other patterns
Vital signs and deterioration of diagnosis to depression.
Exercise
Sleep-rest periods
Food and uid intake
Refer to appropriate community resources prior to discharge. Support groups can encourage progress in building self-esteem,
provide advocacy, and provide long-term support.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Perform a thorough assessment appropriate for the patients Developmentally appropriate assessment will provide cues and
developmental needs to identify specic factors that are causing reveal data to generate a more accurate and complete plan of care.
powerlessness:
Use of art
Use of puppetry
Use of group therapy
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Provide the prospective parents with factual information about Provides basic information that assists the family in decision
the type of choices available for birth, and assist them to identify making, thus promoting empowerment of the family unit.34
their preference:
Traditional obstetric services
Family-centered maternity care units
Single-room maternity care
Mother-baby care
Birthing center
Provide answers to questions in an open, direct manner.
Provide information on all procedures so the patient can make
informed choices:
Assist the patient and signicant others in establishing
realistic goals (list goals with evaluation dates here).
Allow the patient and signicant others to participate in
decision making.
Allow the patient maximum control over the environment. This Decreases perception of powerlessness, and assists in transition to
could include the husbands staying in postpartum room to parenthood.
assist with infant care, keeping the newborn with the mother at
all times, using different positions for birth (e.g., squatting or
hand-knee position), having grandparents and siblings in the
room with the mother and newborn.
Provide positive reinforcement for parenting tasks.
Assist the patient in identifying infant behavior patterns and
understanding how they allow her infant to communicate with
her.
Support the patients decisions, e.g., to breastfeed or not to
breastfeed or who she wants as signicant others during the
birthing process.
Reassure the new mother that it takes time to become
acquainted with her infant.
Support and reassure the mother in learning infant care, e.g.,
breastfeeding, bathing, changing, holding a newborn, cord care,
or bottle-feeding.
Allow the parents to verbalize fears and insecure feelings about Promotes decision making, and leaves decisions up to family by
their new roles as parents. providing the guidance and support that is needed.
Assist the parents in identifying lifestyle adjustments that may
be needed because of the incorporation of a newborn into the
family structure.
Involve signicant others in discussion and problem-solving Involvement enhances motivation to stay with plan, thus
activities regarding role changes within the family. reinforcing decision-making capacity of new parents.67
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Sit with the client [number] times per day at [times] for 30 min Promotes the development of a trusting relationship, and assists
to discuss feelings and perceptions the client has about the the client in identifying factors contributing to the feelings of
identied situation. powerlessness.
Identify client preferences for daily routine, and place this It is vital to this client to have the information shared with all
information on the chart to be implemented by the staff. staff so that it will not appear that the time spent in providing
information was wasted. Promotes the clients perception of
control.
Provide information to questions in an open, direct manner. Facilitates the development of a trusting relationship.
Provide information on all procedures at a time when the client Facilitates the development of a trusting relationship, and
can ask questions and think about the situation. promotes the clients sense of control.
Allow the client to participate in decision making at the level to The client who has never made an independent decision would be
which he or she is capable. If necessary, offer decision situations overwhelmed by the complexity of the decisions made daily by the
in portions that the client can master successfully. (The amount corporation executive. Promotes the clients sense of control.
of information that the client can handle should be noted here
as well as a list of decisions the client has been presented
with.)
Identify the clients needs and how these are currently being met. Assertive direct communication increases the opportunity for the
If these involve indirect methods of inuence, discuss alternative clients needs being met. When the client is successful in getting
direct methods of meeting these needs. (The client who requests needs met in a direct manner, his or her sense of control and
medication for headache every 15 min is requesting attention self-esteem will increase.
and is encouraged to approach the nurse and ask to talk when
the need for attention arises.)
Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while enhancing
decisions made. (Those things that are reinforcing for this client self-esteem.
should be listed here along with the reward system that has
been established with the client, e.g., play one game of cards
with the client when a decision about what to eat for dinner is
made, or walk with the client on hospital grounds when a
decision in made about grooming.)
Provide verbal social reinforcements along with behavioral Promotes the development of a trusting relationship.
reinforcements.
Keep promises (specic promises should be listed here so that
all staff will be aware of this information).
Assist the client in identifying current methods of inuence and Promotes positive orientation by assisting the client in identifying
in understanding that inuence is always there by providing way in which they are already powerful.
feedback on how inuence is being used in the clients
interactions with the nurse.
Accept the clients decisions if the decisions were given to the Promotes the clients sense of control, and enhances self-esteem.
client to be madee.g., if the decision to take or not take
medication was left with the client, the decision not to take the
medication should be respected.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Ensure access to call light, telephone, personal care items, and Increases the patients ability to take control of some aspects of care.
television control.32
Advocate for the patient, ensuring that health care professionals Stereotyping of older adults is problematic in health care
are not leaving the patient out of the decision loop because of professions.68
the patients chronologic age.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Personal involvement and goal setting according to personal wishes
strategies to reduce Powerlessness: enhance the likelihood of success in resolving problem.
Family conference: Identify and discuss strategies.
Mutual goal setting: Agree on goals to reduce Powerlessness.
Identify roles of all participants.
Discuss effective communication techniques.
Assist the client and family in lifestyle adjustments that may be Lifestyle adjustments require permanent changes in behavior.
required: Self-evaluation and support facilitate the success of these lifestyle
Relaxation techniques: Yoga, biofeedback, hypnosis, changes.
breathing techniques, imagery
Providing opportunities for the individual to exert control
over situation, giving choices when possible, supporting and
encouraging self-care efforts
Problem solving and goal setting
Providing sense of mastery and accomplishable goals in secure
environment
(continued)
Copyright 2002 F.A. Davis Company
guiding therapy
condition
Consult with or refer to assistive resources as indicated. Use of existing community resources provides for effective use of
resources.
Assist the client and family to set criteria to help them Early identication of issues requiring professional evaluation will
determine when the intervention of a health care professional increase the probability of successful intervention.
is requirede.g., inability to perform activities of daily living,
or condition has declined rapidly.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has listed Reassess using initial assessment factors.
areas of control such as leisure
time, diet, work hours, and
budget; states, Guess I hadnt
really thought enough about it.
Record RESOLVED. Delete
nursing diagnosis, expected
outcome, target date, and No Is diagnosis validated?
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW, AND RISK FOR SITUATIONAL LOW 509
EXPECTED OUTCOME TARGET DATES
Will list at least [number] positive aspects about self by [date]. A target date of 3 to 5 days would be acceptable to begin monitor-
ing progress.
ACTIONS/INTERVENTIONS RATIONALES
Collaborate with psychiatric nurse clinician regarding care (see Collaboration promotes a more holistic and total plan of care.
Psychiatric Health nursing actions).
Teach the patient and signicant others the patients self-care Participation in own care increases condence and self-esteem.
requirements as needed. Support the patients self-care
management activities.
Control pain with medication, stress management techniques, Conserves energy to focus on adaptive coping strategies.
and diversional activities.
Encourage the patient to use anxiety-reducing techniques, e.g., Assists the patient to reduce anxiety and regain self-control, thus
progressive muscle relaxation, deep breathing, yoga, meditation, increasing self-esteem.
assertiveness, or guided imagery.
Encourage assertive behavior in interacting with the patient. Helps the patient avoid vacillating from one behavior to another.
Assist the patient to review passive and aggressive behavior. Promotes self-control and a win-win situation, which increases
self-esteem.
Promote calm, safe environment by avoiding judgmental Decreases anxiety and promotes a trusting relationship.
attitude, actively listening, using reection, being consistent in
approach, and setting boundaries.
Allow the patient to progress at own rate. Start with simple, Helps the patient have sense of mastering of tasks, and promotes
concrete tasks. Reward success. self-esteem.
Use frequent contact, 15 min every 2 h on [odd/even] hour, Assists in self-understanding and facilitates self-acceptance.
with the patient to encourage verbalization of feelings:
Be honest with the patient.
Point out and limit self-negating statements.
Do not support denial.
Focus on reality and adaptation (not necessarily acceptance).
Set limits on maladaptive behavior.
Focus on realistic goals.
Be aware of own nonverbal communication and behavior.
Avoid moral value judgments.
Encourage the patient to try to note differences in situations
and events.
Help the patient to ascertain why he or she can maintain
self-esteem in one situation and not in another situation.
Build on coping mechanisms or interpretations that maintain Supports adaptive coping, and helps broaden inventory of coping
or increase self-esteem. Assist to nd alternative coping strategies.
mechanisms.
Encourage the patient to use available resources: Decreases feelings of loss, and increases self-esteem when patient
Prosthetic devices does not feel different from previous self.
Assistive devices
Reconstructive and corrective surgery
Refer to and collaborate with community resources. Provides ongoing and long-term support.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributory factors related to poor self-esteem, Generates the database needed to more accurately and completely
including: plan care.
(continued)
Copyright 2002 F.A. Davis Company
Social isolation
Developmental crisis
Identify ways the patient can formulate or reestablish a positive Developmental norms serve as the conceptual framework for
self-esteem according to developmental needs: assisting the child to increase self-esteem.
Coping skills
Communication skills
Role expectations
Self-care
Activities of daily living
Basic physiologic needs; primary health care
Expression of self
Peer and social relationships
Feelings of self-worth
Decision making
Validation of self, e.g., setting developmentally appropriate
expectations
Praise and reinforce positive behavior. Reinforcement of desired behavior serves to enhance permanence
of behavior.
Explore value conicts and their resolution. Values must be claried as one strives to nd ones identity. A
healthy sense of self contributes to a positive self-image.
Collaborate with other health care team members as needed. Collaboration promotes a more holistic plan of care.
Meet primary health needs in an expedient manner. Conserves energy, minimizes stress, and enhances trust.
Provide appropriate attention to other alterations, especially Related issues must be considered as contributing factors to the
those directly affecting this diagnosis such as Risk for Violence diagnosis. Inattention to these factors means resolution of
Provide for follow-up before the child is dismissed from hospital. Attaches value to follow-up, and promotes likelihood of
compliance.
Use developmentally appropriate strategies in care of these Developmentally based strategies are most likely to not frighten
children: the child or parent unnecessarily.
Infant and Toddlers: Play therapy or puppets
Preschoolers: Art
School-agers: Art or role-playing
Adolescents: Discussion or role-playing
Carry out teaching of appropriate health maintenance. This Personal hygiene and self-care will enhance a positive self-esteem
could be the appropriate way of dealing with crisis related to as the patient copes with daily living.
shyness or poor communication skills.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW, AND RISK FOR SITUATIONAL LOW 511
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Fix her hair differently.
Take a walk.
Rest quietly.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Sit with the client [number] minutes [number] times per shift Expression of feelings and concerns in an accepting environment
to discuss the clients feelings about self. can facilitate problem solving.
Answer questions honestly. Promotes the development of a trusting relationship.
Provide feedback to the client about the nurses perceptions of Assists the client with reality testing in a safe, trusting relationship.
the clients abilities and appearance by:
Using I statements
Using references related to the nurses relationship to the
client
Describing the clients behavior in situations
Describing the nurses feelings in relationship
Provide positive reinforcement. List here those things that are Positive reinforcement encourages behavior.
reinforcing for the client and when they are to be used. Also list
here those things that have been identied as nonreinforcers for
this client, and include social rewards.
Provide group interaction with [number] persons [number] Disconrms the clients sense of aloneness, and assists the client to
minutes 3 times a day at [times]. This activity should be gradual experience personal importance to others while enhancing
and within the clients abilitye.g., on admission the client may interpersonal relationship skills. Increasing these competencies
tolerate one person for 5 min. If the interactions are brief, the can enhance self-esteem and promote positive orientation.
frequency should be highi.e., 5-min interactions should occur
at 30-min intervals.
Protect the client from harm by: Client safety is of primary concern.
Removing all sharp objects from environment
Removing belts and strings from environment
Providing a one-to-one constant interaction if risk for
self-harm is high
Checking on the clients whereabouts every 15 min
Removing glass objects from environment
Removing locks from room and bathroom doors
Providing a shower curtain that will not support weight
Checking to see whether the client swallows medications
In a supportive attitude and manner, reect back to the client Increases the clients awareness of negative evaluations of self.
negative self-statements he or she makes.
Set achievable goals for the client. Goals that can be accomplished increase the clients perceptions of
power and enhance self-esteem.
Provide activities that the client can accomplish and that the Activities the client nds demeaning could reinforce the clients
client values. negative self-evaluation. Accomplishment of valued tasks provides
positive reinforcement and enhances self-esteem.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient in developing self-care skills needed for Enhances perception of control over the situation.
managing the current illness.70
Assist the patient in identifying his or her unique abilities, and Increases recognition of successes that come from the use of
relate the benets you as a nurse receive from your interactions personal strengths.
with the patient.70
Review the patients current abilities and how they may require Increases perception of functional ability in preferred life roles.
role modication.70
Assist with personal grooming needs, such as removal of excess Attention to personal appearance can have a positive inuence on
facial hair and use of cosmetics, where applicable.71 self-esteem and thus perception of the individual.
Copyright 2002 F.A. Davis Company
SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW, AND RISK FOR SITUATIONAL LOW 513
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement improves effectiveness of implementation.
strategies to reduce and cope with disturbance in self-esteem:
Family conference: Discuss perceptions of the clients
situations and identify realistic strategies.
Mutual goal setting: Establish goals and identify roles of
Communication.
Assist the client and family in lifestyle adjustments that may be Lifestyle changes require long-term changes in behavior. Such
required72: changes in behavior require support.
Obtaining and providing accurate information
Clarifying misconceptions
Maintaining safe environment
Encouraging appropriate self-care without encouraging
dependence or expecting unrealistic independence
Providing opportunity for expressing feelings
Realistic goal-setting
Providing sense of mastery and accomplishable goals in
secure environment
Altering roles
Consult with or refer to assistive resources as indicated. Utilization of existing services is efcient use of resources.
Psychiatric nurse clinician and support groups can enhance the
treatment plan.
Copyright 2002 F.A. Davis Company
Yes No
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
NOTE: Should this diagnosis be made on an adult health patient, immediately refer him or her to a
mental health practitioner. See Psychiatric Health nursing actions.
Child Health
NOTE: Refer patient to a mental health practitioner. See Psychiatric Health nursing actions related to
this diagnosis.
Womens Health
The nursing actions for the woman with this diagnosis would be the same as those given for the mental
health patient.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Sit with the client [number] minutes [number] times per shift at Promotes the development of a trusting relationship, while
[times] to assess the clients mood, distress, needs, and feelings. providing a nonintrusive manner.73
Place the client on a frequent observation schedule. Note that Client safety is of primary importance. Increased attention may
schedule here. This observation should take place in a inadvertently reinforce injury if it occurs in relation to self-injury
nonintrusive manner. episodes.73
Remove from the environment any object that could be used to Client safety is of primary importance.
harm self.
Use one-to-one observation to protect the client during periods Physical and chemical restraints have been demonstrated to
of risk for self-harming behavior. escalate behavior. At times clients may escalate their behavior to be
placed in restraints.74
Develop a baseline assessment of the self-injury patterns. This Provides baseline information on which to base criteria for
should include frequency of behavior, type of behavior, factors behavioral change. Provides positive reinforcement.
related to self-harm, and effects of self-harm on the client and
other clients. Note this information here.
Answer the clients questions honestly. Promotes the development of a trusting relationship.
Reframe the clients self-harming behavior as habitual behavior Promotes a positive orientation, and supports the clients
that can be changed as any habit. While doing this, do not strengths.75
diminish the clients experience of pain and discomfort.
Identify, with the client, goals that are reasonable. Note those Assists the client in gaining internal control of problematic
goals heree.g., the client will contact staff when feeling need behaviors.75 Achieving goals provides reinforcement of positive
to harm self. behavior and enhances self-esteem.
(continued)
Copyright 2002 F.A. Davis Company
exaggerations.76
Identify with the client strategies that can be utilized to cope Promotes the clients sense of control, and assists the client with
with these situations. Note the identied strategies here. cognitive preparation for coping with these situations.76
Select one identied strategy and spend 30 min a day at [times] Behavioral rehearsal provides opportunities for feedback and
practicing this with the client. This could be in the form of a modeling from the nurse.
role-play. Note here the person responsible for this practice.
Meet with the client just prior to and after trigger situations to Promotes the clients sense of control, and provides an opportunity
assist with planning coping strategies and processing outcome for the nurse to provide positive reinforcement for adaptive coping
to revise plans for future situations.74 mechanisms.
Initiate the clients coping strategy or provide distraction, such Provides opportunity for the client to practice new behaviors in a
as physical activity, when the client identies that the urge to supportive environment where positive feedback can be provided.
harm himself or herself is strong. Acknowledge that the Promotes the clients sense of control, and enhances self-esteem.
distraction will not increase comfort as much as self-harm Promotes positive orientation.
would at the present time, but the feelings of mastery will be
satisfying.75
Identify, with the client, areas of social skill decits, and Enhances interpersonal skills by providing the client with more
develop a plan for improving these areas. This could include adaptive ways of achieving interpersonal goals.
assertiveness training, communication skills training, and/or
relaxation training to reduce anxiety in trigger situations. Note
plan and schedule for implementation here. This should be a
progressive plan with rewards for accomplishment of each
step.7476
Develop a schedule for the client to attend group therapies. Provides an opportunity for the client to practice interpersonal
Note this schedule here. skills in a supportive environment and to observe peers modeling
interpersonal skills.
Meet with the client and the clients support system to plan
coping strategies that can be used at home. Assist system in
obtaining resources necessary to implement this plan.
In the event that self-mutilation does occur, provide the Prevents loss of function and further injury.
necessary rst aid in a matter-of-fact manner.
Avoid elaborate focusing on the injury. Prevents the development of secondary gains from self-injury.77
Sit with the client for [number] minutes to discuss the Supports the development of appropriate methods of coping with
feelings that preceded the act. feelings.
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis would be the same as those given for the
mental health patient.
Home Health
See Psychiatric Health nursing actions for additional interventions.
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to risk for self-mutilation. Provides database for early recognition and intervention.
Involve the client and family in planning, implementing, and Family involvement enhances effectiveness of interventions.
promoting reduction or elimination of risk for self-mutilation:
Family conference: Discuss perspective of each family member.
Mutual goal setting: Develop short- and long-term goals with
evaluative criteria. Tasks and roles of each family member
should be specied.
Communication: Open, direct, reality-oriented
communication.
(continued)
Copyright 2002 F.A. Davis Company
No Yes
Record data, e.g., has made Reassess using initial assessment factors.
no threats of or attempts at
self-mutilation since day 2
of admission; making positive
self-statements, attending group,
and actively participating.
Record RESOLVED (may wish to
use CONTINUE until patient No Is diagnosis validated?
discharged). Delete nursing
diagnosis, expected outcome,
target date, and nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 9
Role-Relationship Pattern
520
Copyright 2002 F.A. Davis Company
role expectations. Roles can be mediated through role-playing skills Husband and wife Economic specialization and cooperation,
and self-conceptions. It is hoped that with the increased demands on sexual cohabitation; joint responsibility for support, care,
the individual, society will continue to value human dignity with re- and upbringing of children; well-dened reciprocal rights
spect for life itself. Roles should allow for self-actualization. with respect to property, divorce, and spheres of authority
One of the more recent eclectic theories of personality develop- Father and son Economic cooperation in masculine activities
ment encompassing role theory is that of symbolic interaction. In this under leadership of the father; obligation of material support
orientation, social interaction has symbolic meaning to the partici- vested in father during childhood of son and in son during
pants in relation to the roles assigned by society. (For further re- old age of father; responsibility of father for instruction and
lated conceptual information, refer to Chapter 8, Self-Perception discipline of son; duty of obedience and respect on part of
and Self-Concept Pattern.) son; tempered by some measure of comradeship
Symbolic interaction encompasses the roles assumed by humans Mother and daughter Relationship parallel to that between fa-
in their constant interaction with other humans, communicating ther and son, but with more emphasis on child care and eco-
symbolically in almost all they do. This interaction has meaning to nomic cooperation and less on authority and material sup-
both the giver and the receiver of the action, thus requiring both port (However, strong relationships in the development of
persons to interact symbolically with themselves as they interact mothering skills and parenting techniques lead to obligations
with each other. Symbolic interaction involves interpretation, that of emotional support and caretaking activities vested in the
is, ascertaining the meaning of the actions or remarks of the other mother during the childhood of daughter and in daughter
person, and denition, that is, conveying indication to another per- during old age of mother.)
son as to how he or she is to act. Human association consists of a Father and daughter Responsibility of father for protection and
process of such interpretation and denition. Through this process, material support prior to marriage of daughter; economic co-
the participants t their own acts to the ongoing acts of one another operation, instruction, and discipline appreciably less promi-
and guide others in doing so.2 nent than in father-son relationship; playfulness common in
To explore further how relationships develop, a brief overview of infancy of daughter, but normally yields to a measure of re-
kinship is offered. A kinship system is a structured system of rela- serve with the development of a strong incest taboo
tionships in which individuals are bound one to another by com- Mother and son Relationship parallel to mother and daughter
plex, interlocking relationships. These relationships are commonly but with more emphasis on nancial and emotional support
referred to as families. It is not so much the family form in which in later life of mother
one lives as how that family form functions that denes whether or Elder and younger brother Relationship of playmates, devel-
not there is a cohesive family structure: oping into that of comrades; economic cooperation under
leadership of elder; moderate responsibility of elder for in-
An ideal family environment consists of a family that has many rou- struction and discipline of younger
tines and traditions, provides for quality time between adults and Elder and younger sister Relationship parallel to that between
children, has regular contact with relatives and neighbors, lives in a
elder and younger brother, but with more emphasis on phys-
supportive and safe neighborhood, has contact with the work world
ical care of the younger sister
and has adult members who model a harmonious and problem-
solving relationship. (pp. 505506)3 Brother and sister Early relationship of playmates, varying
with relative age; gradual development of an incest taboo,
The 1980s saw great change in family structures with an explo- commonly coupled with some measure of reserve; moderate
sion of individualized living arrangements and lifestyles requiring economic cooperation; partial assumption of parental role,
new denitions of the family.36 Fewer nuclear families consist- especially by the elder sibling
ing of husband, wife, and children exist today, and this is no longer
the only acceptable form for family life. The following are some of The nurse must exercise great caution in maintaining sensitivity
the different family forms identied in todays society.36 to the individual meaning attached to various roles and the way in
which these roles are perceived and assumed. With the current so-
Nuclear family Husband, wife, and children living in a com- cietal and economic changes, the individuals roles are being im-
mon household, sanctioned by marriage pacted on a daily basis even without the added stress of a health
Nuclear dyad Husband and wife alone; childless or children problem.
have left home
Single-parent family One head of household, mother or fa- Developmental Considerations
ther, as a result of divorce, abandonment, or separation
Single adult alone Either by choice, divorce, or death of a NEONATE AND INFANT
spouse
Three-generation family Three or more generations in a single The newborn period is especially critical for the development of the
household rst attachment that is so vital for all future human relationships.
Kin network Nuclear households or unmarried members liv- Attachment behavior includes crying, smiling, clinging, following,
ing in close geographic proximity and cuddling. The infant is dependent on its mother and father for
Institutional family Children in orphanages or residential basic needs of survival. This is often demanding and requires par-
schools ents to place self-needs secondary to the needs of the infant. This
Homosexual family Homosexual couples with or without makes for a potential role-relationship alteration.
children Although dependent on others, the infant is an active participant
in role-relationship pattern development from conception on. The
Despite the differences in family forms and cultural differences, infant is capable of inuencing the interactions of those caring for
primary relationships within various family structures reveal him or her. Reciprocal interactions also inuence the maternal-
markedly similar characteristics in all societies. These relationships paternal-infant relationship. Positive interactions will be greatly in-
were described in 19497 and still exist in the various family forms uenced by infant-initiated behavior as well as maternal-paternal
cited today: responses and the reciprocal interaction of all involved. The state of
Copyright 2002 F.A. Davis Company
caregivers or others or may manifest frustration via extremes in de- This child is at risk of social isolation if a situation is different from
manding behavior. The childs subsequent development may also previous socialization opportunities. He or she may experience value
be affected by family process alteration. conict and question the rules. He or she may also be afraid to ex-
The preschool child is able to verbalize concerns regarding press desires or concerns regarding socialization needs for fear of
changes in family process but is unable to comprehend dynamics. It punishment. Peer involvement is a most vital component of assisting
is critical to attempt to view the altered process through the eyes of the school-ager to formulate views of acceptable social behavior.
the preschooler who could blame himself or herself for the change or The school-ager may try to assume the role of a parent if the dys-
crisis, or who may think magically and have fears that may be unre- function of the family relates to the parent of the same sex. This may
lated to the situation. Subsequent development may be altered by be healthy with appropriate acknowledgment of limitations. At this
family process dysfunction, with regression often occurring. age, the child is concerned with what other friends may think about
At this age, it is important to stress the need for ritualistic be- the family, with some stigma attached in certain cultures to divorce,
havior as a means of mastering the environment with adequate an- homosexuality, and altered lifestyles. It would be critical for the
ticipatory safety. This period allows for knowing self as a separate school-ager to have a close friend who might share the cultural
entity. The toddler is capable of attempting to conform to social de- views of his or her own family to best endure the altered family
mands but lacks ability of self-control. process.
The importance of setting limits must be stressed with regard to Allowance for increasing interests outside the home should be
safety and disciplinary management. At this age, the child begins to made with sensitivity to parental approval or disapproval. The child
resist parental authority. Methods of dealing with differences or may rebel against parental authority in an attempt to be like peers.
rules from one setting to another must be simple and appropriate Condence in self and a general sense of well-being will promote
to the situation. adequacy in communication development. The child of this age
For the toddler, this time can prove frustrating, with a need to be continues to learn vocabulary and takes pride in his or her ability
understood despite a limited vocabulary. Jargon and gestures may to demonstrate appropriate use of words. At this age, jokes and rid-
be misinterpreted, with resultant frustration for the child and the dles serve as a means of encouraging peer interaction with speech.
parent. Patience and understanding go far with a child of this age. Reading is a leisure activity for the school-age child.
Pictures and the telling of stories serve as means of enhancing The child will usually enjoy school and consider peer interaction
speech as well as instilling an appreciation for reading and speech. an enjoyable part of life. In instances in which the child feels infe-
Feelings come to be expressed by the spoken word also. The child rior, there may be a risk for violence or abusive behavior as a cover-
is able to refer to self as I, me, or by name. up for poor self-image or low self-esteem. Often there will be re-
By preschool age, the child is able to count to 10, is able to de- lated role-relationship alterations as well. The family serves as a
ne at least one word, and may name four or ve colors. Speech means of valuing the interaction, which should foster the appro-
now serves as a part of socialization in play with peers. Wants priate enjoyment of friendships. At risk would be those children
should be expressed freely as the child broadens his or her contact with learning disabilities or handicaps, parental conicts, or related
with persons other than primary family members. The preschooler role-relationship alteration.
enjoys stories and television programs and attempts to tell stories
of his or her own creation. ADOLESCENT
If the toddler is unable to fulll the expectations of parents or
caregivers who demand unrealistic behavior, there is risk of abuse. Vacillation between dependence and independence is a common
Especially noteworthy would be a desire for the young toddler to occurrence for the adolescent who is attempting to establish a sense
be capable of self-toileting behavior when in fact such is not possi- of identity. The adolescent questions traditional values, especially
ble. This places the toddler in a target population for abuse also. At those of parents. There is a gradual trend to independent function-
this age, the toddler may be unable to express hostility or anger in ing that allows the adolescent to assume roles of adulthood, in-
the verbal mode, and so a common occurrence may be temper cluding the development of intensive relationships with members
tantrums. At risk for violence would be the toddler who resists of the opposite sex.
parental authority in discipline and cannot meet demands of the The adolescent will be constantly weighing self-identity versus
parents. perceived identity expressed via peers. He or she may be fearful of
expressing true feelings or concern for fear of rejection by peers,
SCHOOL-AGE CHILD parents, or signicant others. Isolation from peers places the ado-
lescent at risk for altered self-identity as well as altered role-
Learning social roles as male or female is a major task for the school- relationship patterns.
age child, with a preference for spending time with friends of the The adolescent is able to assist within the family during times of
same sex rather than the family. The school-ager is capable of role- altered process. It is important to stress that in more and more dual-
taking and values cooperation and fair play. There may be a strict career or single-parent families, young adolescents spend more and
moralism of black and white with no gray areas noted. The more time alone. Nonetheless, adolescents should still have oppor-
school-ager enjoys simple household chores, likes a reward system, tunities for peer interaction and socialization according to the fam-
and has the capacity for expressing feelings. Fear of disability and ilys needs.
concern for missing school are typical concerns for this age group. There may be marked vacillations, as the adolescent strives to
Illness may impose separation from the peer group. Although in- nd self-identity, with dependence and independence issues. Even
dependent of parents in health, the school-ager may require close more marked rebellion against parental wishes may be manifest at
parental relationship in illness or crisis. Loss of control and fear of this time as peer approval is sought.
mutilation and death are real concerns. The school-age child may Any factors that may interfere with usual speech patterns may
fear disgracing parents if loss of control such as crying occurs. He prove especially difcult for the adolescent. Bracing of teeth may be
or she is aware of the severity of his or her prognosis and may even common, with the potential for self-image alteration. Also, the
deal with reality better than parents or adults might. The school- eruption of 12-year molars could prove painful, as might the pos-
age child may use art as a means of expressing his or her feelings. sible impaction of wisdom teeth later. Expressed wit is valued in
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the patient to talk about caregiver role by active Decreases anxiety when allowed to ventilate positive and negative
listening, reection, open-ended questions, accepting his or feelings in nonthreatening, empathetic environment.
her feelings for 15 min twice a day at [times].
Teach stress management techniques such as relaxation,
meditation, or deep breathing.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributing factors with a focus on high-risk Unrealistic demands of parenting or care provision increase the
populations: likelihood of role strain.
Excessive demands exist secondary to a child requiring
extensive care, e.g., several small children in family with one
problems
Schedule a daily conference with the caregiver of at least 30 min. Allows identication of current perception of role strain by
encouraging ventilation of feelings. Provides a teaching
opportunity. Assists in identication of referrals that are
needed.
Explore with the parent or caregiver, during conference, options Support from others serves as a means of preventing further
available to assist with the demands of the situation. Encourage demise of desired role-taking while also allowing for long-term
the caregiver to provide time for self on a daily basis through needs. Time for self will enhance coping abilities and, ultimately,
such means as seeking outside helpe.g., visiting nurse, self-esteem.
housekeeping assistance, respite care, institutionalization such
as temporary per day or, if appropriate and desired,
permanent.
Identify, during conference, community resources that are Provides long-term support and information. Encourages sharing
available, especially parenting support groups. of concerns with others in the same situation.
Schedule family conference, as needed, to focus on the familys Assists in delineating roles for each family member. Assists in
willingness to provide assistance in caregiving. providing relief for the primary caregiver on a more regular
basis.
Determine, via an ongoing assessment, any unresolved guilt Unresolved conict increases the likelihood of little change in
regarding role demands, less-than-perfect child, or related behavior.
aspects of situation (see Dysfunctional Grieving).
Assist the caregiver and signicant other(s) to explore, during Expectations may be unrealistic. Clarication of expectations and
conference, inevitabilities and realities associated with the care reality assist in problem solving.
situation.
Preserve the effective functioning of the caregiver through The likelihood of secondary and tertiary alterations for the
teaching and support in conferences. caregiver increase when primary needs of rest and own physical
self are not met.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
NOTE: For information related to the caregivers of those clients with a medical diagnosis of demen-
tia, refer to Gerontic Health. As used in this discussion, caregiver can mean one person or an ex-
tended family system.
ACTIONS/INTERVENTIONS RATIONALES
Spend [number] minutes [number] times per week interacting Promotes the development of a trusting relationship.
with the primary caregiver.
Provide a role model for effective communication by: Family problem solving is improved when the family members
Seeking clarication can effectively communicate with one another and the health care
Demonstrating respect for individual family members and team.13
the family system
Listening to expression of thoughts and feelings
Setting clear limits
Being consistent
Include the caregiver in weekly treatment planning meetings Assists in providing information to the caregiving system so they
with the client. Note here the time for this meeting and persons can better cope with the uncertainty of a psychiatric diagnosis.13,14
responsible for providing the information.
Provide the family with opportunities to provide the care and Provides the family with a sense of helpfulness and control.14
support they identify as important. Note here the care the
family is going to provide, with the assistance they need to
complete these activities.
Spend [number] minutes [number] times per week educating Provides the caregiver with an increased understanding of the
the primary caregiver about the clients diagnosis. Provide both diagnosis, and assists in the development of a home care plan.
written and verbal information. When anxiety is high, caregivers may have difculty remembering
information provided only in verbal form. Increases the stability in
the living environment by decreasing the caregivers anxiety.
(continued)
Copyright 2002 F.A. Davis Company
Commend the family on their competencies and strengths, Provides caregivers an opportunity to change their self-view,
e.g., comment on what the caregiver has said or done that is which opens them up to viewing the problem differently, and
effective and useful. move toward solutions that are more effective.15
Normalize the caregivers feelings of guilt and/or ambivalence by Promotes a positive orientation, and enhances self-esteem.
informing him or her that these are normal feelings for anyone
who assumes the level of responsibility that he or she has
assumed.
Have the caregiver identify areas where he or she feels a need Promotes the caregivers sense of control, and provides positive
for support on a daily basis, and assist him or her in networking reinforcement when he or she can accomplish the task, which
community resources to meet these needs. This should be a enhances self-esteem.
process that allows the nurse to teach the caregiver the skills
necessary to accomplish this networking on his or her own after
discharge.
Spend [number] minutes [number] times per week discussing Gives permission to the caregiver to care for self. Promotes the
his or her self-care activities. This could include planning time caregivers strengths.
away from the client, inviting friends to visit, going for a walk,
or arranging to get uninterrupted sleep. Inform the caregiver
that if he or she does not care for himself or herself, he or she
will eventually not have the energy to care for the client. A
specic plan should be developed and noted here.
Before the client is discharged, meet with the client and Anxiety can decrease an individuals ability to process information
caregiver to: during hospitalization. A specic coping plan provides direction
Review information about the diagnosis and hospital course. during times of crisis and prevents the reliance on ineffective
Review special treatments the client is to receive. patterns of coping. These actions increase the caregivers repertoire
Explain the clients medications. of strategies to deal with the problems.16
Anticipate problems that may arise after discharge.
A specic plan should be developed for coping with anticipated
problems. This plan should be written down and given to both
the client and the caregiver.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for signs of increasing strain in the caregiver, such as The stresses of caregiving have a negative effect on the caregivers
an increase in episodes of illness. immune system.17
Assist the caregiver in discussing feelings about caregiving. For Provides opportunity for ventilation of feelings about caregiving,
example, encourage sharing by use of statements such as Often which assists in reducing stress.
people in your situation say they feel angry, helpless, guilty, or
depressed.
Determine the caregivers knowledge of support services in the Assists in identifying actual or potential resources based on the
community, such as adult daycare, respite services, or family individuals current knowledge of services. Expands options
support groups. available to the caregiver.
Discuss with the caregiver stress management techniques such
as imagery, deep breathing, or exercise. What has been tried?
How helpful was it?
Encourage the caregiver to use a journal to evaluate stresses, Provides database to use in planning interventions to reduce stress.
prioritizing stresses and noting his or her usual response. Are
there specic times, days, or circumstances when stress is
especially high?
(continued)
Copyright 2002 F.A. Davis Company
Home Health
See Psychiatric Health section for additional interventions.
ACTIONS/INTERVENTIONS RATIONALES
Consult with and/or refer the patient to assistive resources, such Utilization of existing services is an efcient use of resources.
as caregiver support groups, as needed.
Provide respite care for the client to allow the caregiver rest as To allow for caregiver physical and emotional rest, which
nances allow. promotes the best possible care for the client.
Educate all family members about critical care issues for the Knowledge helps promote a sense of control and order, as well
client, and encourage the primary caregiver to delegate as more appropriate delegation of tasks. Delegation promotes
caregiving responsibilities as appropriate. caregiver physical and emotional rest, which enhances client care.
Help the caregiver identify positive outcomes related to Positive feelings can balance negative feelings and provide a sense
caregiving (e.g., increased relationship intimacy and feeling of purpose.
valued in the relationship) to balance negative feelings.
Provide written documentation of caregiving responsibilities as To assist the caregiver in obtaining time away from work if needed
needed for the caregivers employers. to provide care.
Copyright 2002 F.A. Davis Company
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor interaction styles, communication patterns, and role Baseline information about family dynamics can assist the nurse
behaviors in the family.19 with planning and developing family interventions.
Promote a trusting therapeutic relationship during interaction Provides comfort, and aids in crisis resolution.
with the patient and family by being empathetic, actively
listening, accepting feelings and attitudes, and being
nonjudgmental.
Promote open, honest communications among the family Promotes verbalization of feelings and shared understanding of
members by facilitating group interaction. Encourage the patient problems. Assists the family to acknowledge and accept the
and family to express feelings regarding current family process problem. Promotes a common denition of the problem, and
by spending [specic time] each shift, while awake, for this assists in identifying ways to cope with the problem.
purpose.
Determine the familys level of recognition of problems within Level of recognition may serve as an indicator of the familys
the family unit associated with the patients alcoholism. acceptance or denial of problems.
Allow the family to grieve by providing time, giving permission, Assists in crisis intervention, and provides extra coping
and referring them to clergy and/or bereavement group. mechanisms.
(continued)
Copyright 2002 F.A. Davis Company
See Psychiatric Health nursing actions for more detailed Collaboration promotes more holistic care; many need specic
interventions. interventions by a specialist.
Child Health
NOTE: Depending on the age of the infant or child, there may be a range of possible needs represented
in the context of the familyall interventions should be developmentally appropriate. Include all
children in family counseling as applicable.
ACTIONS/INTERVENTIONS RATIONALES
Promote sibling participation in the patients hospitalization and Inclusion of sibling(s) fosters a sense of family concern, and need
plans for discharge, e.g., allowing visitation during game time. for support is met for all involved. Undue prolonged separations
increase stress for the sibling(s) and family relationships.
Provide for cultural preferences when possible, including diet, Attention to preferences demonstrates valuing and sensitivity for
religious needs, and plans for health care. the family.
Provide reinforcement to appropriately value caretaking Reinforcement of desired behaviors serves to offer positive
behavior. learning, with increased likelihood of compliance.
Advocate on the infants or childs behalf to best offer The infant, child, or adolescent may be unable to look after
management of alcohol or substance abuse impact on current self-interests, and when this is so, it is legally and morally
or future development. mandated that the client have an advocate.
Determine the childs or adolescents feelings of the family per Assists in anxiety reduction, and values input of all individual
ventilation about same for 30 min each shift. family members. Also, data may be known for best treatment.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
NEW PARENTS
Assist the patient and signicant others in establishing realistic Assist the family with role changes during a normal, but often
goals related to changes in role due to newborn, e.g., sharing of unexpected, amount of role change event. Provides basis for
tasks or parenting skills. planning necessary changes.
Provide positive reinforcement for parenting tasks. Provides motivation, and enhances likelihood of effective parenting.
Assist the parents in identifying infant behavior patterns and Assists in reducing stress, and promotes positive parenting.
understanding how they allow the infant to communicate with
them, e.g., crying or fussing.
Assist the patient in verbalizing her perceptions of the infants Provides database that allows more effective teaching and planning
growth and development, individual and family needs, and the for effective parenting.
stresses of being a new parent.
Identify support groups, e.g., formal groups, such as Mothers Day Promotes planning, and allows early intervention for potential
Out, and informal groups, such as parenting groups, family, stress areas.
or friends.
Encourage open communication between the mother and father
on household tasks, discipline, fears, and anxieties, e.g.,
less-than-perfect baby.
(continued)
Copyright 2002 F.A. Davis Company
ALCOHOLISM
NOTE: Interventions under Adult Health and Psychiatric Health
will apply here, in addition to the following:
Perinatal
Check your states laws. Because of the widespread drug use in
this country, some states have mandatory screening for drug
use during the perinatal period.20,21
Screen clients for chemical use during pregnancy by means of
interview at rst visit. Provide a relaxed, secure atmosphere for
the client when trying to obtain a substance-abuse history.
Include the following in your questions:
Use of nonprescription drugs
Use of coffee
Use of cigarettes
Use of alcohol
Use of prescription drugs
Use of recreational drugs, such as marijuana
Use of multiple drugs
Problems encountered in trying to abstain from drug use
Assure the client of acceptance for her and her family but not
for self-destructive behaviors.22
Support and praise the client for health-seeking behaviors.22
Thoroughly assess the woman and fetus who present with
complications related to substance abuse in order to
provide the best physiologic support for her and her fetal
well-being.
Obtain sample for toxicology screening:
Maternal or neonatal urine toxicology screen
(continued)
Copyright 2002 F.A. Davis Company
ACTIONS/INTERVENTIONS RATIONALES
Provide a role model for effective communication by: Communication skills provide a framework for effective problem
Seeking clarication solving.
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 system Outcome improves when psychosocial problems are treated from
problems by: a systems perspective.15
Not taking sides in family disagreements
Providing alternative explanations of behavior that recognize
the contributions of all persons involved with the problem,
including health care providers as appropriate
Requesting the perspective of multiple family members on a
problem or stressor
Include all family members in the rst interview. Provides opportunity to assess all family members perception of
the problem and in identication of problem-solving strategies
that are acceptable to more family members.
Have each member provide his or her perspective to the current Assists the family in dening a problem that can be resolved. For
difculties. example, rather than dening the problem as We dont love each
other any more, the problem can be dened as We do not spend
time together in family activities. This denition evolves from the
familys description of what they mean by the more general
problem description.
Assist the family in developing behavioral short-term goals by: Setting achievable goals increases the opportunities for success,
Asking what they would see happening in the family if the which increases the motivation to continue to work toward
situation improved problem resolution.
Having them break the problem into several parts that
combine to form the identied stressor
Asking them what they could do in a week to improve the
situation (should include a response from each family
member)
Maintain the nurses role of facilitator of family communication Maintains a context that enhances and supports the familys
by: problem-solving skills.
Having family members discuss possible solutions among
themselves
Having each family member talk about how he or she might
contribute to both the problem and the problems resolution
Provide the family with the information necessary for
appropriate problem solving.
(continued)
Copyright 2002 F.A. Davis Company
Maintain and support functional family rolee.g., allow the Provides positive reinforcement for functional interactions, and
parents private time alone, allow the children to visit parents, serves to encourage this behavior while enhancing self-esteem.
and encourage the presenting of problems to the family
leader.
Schedule a time with the family to discuss how the current
situation affects family roles and possible changes that may be
necessary.
Have the family identify those systems in the community that Promotes and develops the familys strengths.
could support them during this time, and assist the family in
contacting these systems. Note here the systems to be contacted
as well as how they will assist the family.
Provide positive verbal reinforcement for the familys Positive reinforcement encourages behavior and enhances
accomplishments. self-esteem.
Assist the family in identifying patterns of interaction that Facilitates the development of more appropriate coping behaviors.
interfere with successful problem resolutione.g., the husband
frequently asks his wife closed-ended questions, which
discourages her from sharing her ideas; the children interrupt
the parents when their level of conict increases to a certain
level; or the wife walks out of the room when the husband
brings up issues related to nances.
Assist the family in planning fun activities together. This could Families in crisis often limit their emotional experience.
include time to play together, exercise together, or engage in a
shared project.
Teach the family methods of anxiety reduction, establish a Relaxation response inhibits the activation of the autonomic
practice schedule and a schedule for discussing how this nervous systems ght-or-ight response. Repeated practice of a
method could be used on a daily basis in the family. The behavior internalizes and personalizes the behavior.
selected method along with the schedule for discussion and
practice should be listed here.
Include the family in discussions related to planning care and Support system involvement in problem solving increases the
sharing information about the clients condition. opportunities for a more positive outcome.
Assist the family in developing a specic plan when the client is Promotes the clients sense of control. Planned coping strategies
scheduled for a pass or discharge. Note that plan here, with the facilitate the enactment of new behaviors when stress is
assistance needed from the nursing staff for implementation. experienced. This increases the opportunities for successful coping
and enhances self-esteem.
ALCOHOL
Promote a trusting therapeutic relationship during interaction Provides comfort, and aids in the development of a context that
with the client and family by being empathetic, listening supports expressions of emotions and risking change.23
actively, accepting feelings and attitudes, and being
nonjudgmental.
Spend time in the initial interactions with the family discussing Assists the family in viewing the problem as outside of themselves,
the inuence the problem or illness has on their lives and the objectifying the problem rather than the person, thus making it
inuence they have on the problem. easier for the family to see the problem as something they can
inuence. Assists the family in developing a different perspective
of the problem.15
Establish a therapeutic relationship with whatever part of the Working with the nonalcoholic spouse and family members can
family system initiates treatment. facilitate the entry of the alcoholic family member into treatment.24
Promote open, honest communications among the family Promotes verbalization of feelings and shared understanding of
members by facilitating group interaction. Promote the problems. Assists the family to acknowledge and accept the
expression of feelings regarding current family process by problem. Promotes a common denition of the problem, and
spending [specic time] each shift, while awake, for this assists in identifying ways to cope.
purpose.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
NOTE: The nursing actions for the gerontic patient with this diagnosis would be the same as those
given in Adult Health and Psychiatric Health. The prevalence of alcoholism in older adults is report-
edly lower than in the general population; however, this may be due to the lack of age-specic screen-
ing instruments.26 In older adults, there may be late-onset alcoholism due to an increase in the stresses
associated with aging. Such things as the loss of a spouse, changes in health, and retirement may pre-
cipitate alcohol abuse.27 Some researchers advocate programs that are connected to aging service pro-
grams, such as senior programs, to assist the older alcoholic and his or her family in dealing with ag-
ing issues as well as alcoholism.28
Home Health
See Psychiatric Health nursing actions for detailed psychosocial interventions.
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family appropriate information regarding Basic knowledge that contributes to successful family functioning.
the care of family members:
Discipline strategies appropriate for developmental level
Normal growth and development
Expected family life cycles, e.g., childrearing or grandparenting
Coping strategies for family growth
Care of health deviations
Developing and using support networks
Safe environment for family members
Anticipatory guidance regarding growth and development,
discipline, family functioning, responses to illness, role
changes, etc.
Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention.
strategies to decrease or prevent alterations in family process:
Family conference to ascertain perspective of members on
current situation and to identify strategies to improve
situation
Mutual goal setting to identify realistic goals with evaluation
criteria and specic activities for each family member
Encouragement of clear, consistent, and honest
communication with positive feedback
Distribution of family tasks so that all members are involved
in maintaining family based on developmental capacity
Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior and family roles require support.
required:
Separation or divorce
Temporary stay in community shelter
Family therapy
Communication of feelings
Stress reduction
Identication of potential for violence
(continued)
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., all helped Reassess using initial assessment factors.
to design plan; plan is written
and posted on refrigerator as a
reminder; all have verbally
indicated understanding of
and commitment to plan.
Record RESOLVED. Delete
nursing diagnosis, expected No Is diagnosis validated?
outcome, target date, and
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
For this diagnosis, the Psychiatric Health nursing actions serve as the generic actions. Please see those actions.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Spend at least 30 min every 8 h (or as situation dictates) to A structured discussion places value on the importance of grieving
address specic anticipated loss by: and provides critical data for the plan of care.
Encouraging the patient and family to express perception of
current situation (may be facilitated by age and developmentally
appropriate intervention such as drawing, play, or puppet
therapy)
(continued)
Copyright 2002 F.A. Davis Company
Collaborate with appropriate health care professional members Appropriate collaboration and coordination of efforts results in
to meet needs of the patient and family in realistically more holistic versus fragmented care at a time of special need. A
anticipating loss. sense of support remains long after the event itself.
Encourage the patient and family to realistically develop coping Fostering coping strategies provides an opportunity for growth
strategies to best prepare for anticipated loss through: with minimal support from others, thereby increasing
Engaging in diversional activities of choice empowerment for the family.
Reminiscing of times spent with loved one or associated with
anticipated loss
Encourage optimal function for as long as possible, with Participation in usual daily activities provides a sense of normalcy
identication of need for proper attention to rest, diet, and despite impending loss and provides validation of life.
health of all family members at this time of stress.
Promote parental and sibling participation in care of the infant Maintenance of family input and participation in care offers
or child according to situation: continuation of the family unit at a time when unity can serve to
Feedings and selection of menu positively inuence daily coping for all.
Comfort measures such as holding the child or giving
backrubs
resuscitation
Reassure the infant or child that he or she is loved and cared for, Reassurance lessens the likelihood of guilt while demonstrating
with ample opportunities to answer questions regarding specic there is no need for assignment of blame to any member of the
anticipated loss whether related to self or others. According to family.
age and developmental status, provide reassurance that cause
for situation is not the patients own doing.
Remember that hearing is one of the last of the senses to remain Speaking can serve to reassure the child of worth; urge caution in
functional. Exercise opportunities for loved ones and staff to conversations that indicate the child cannot hear.
continue to address the patient even though the patient may be
unable to answer or respond.
Provide for appropriate safety and maintenance related to Standard practice requires safety maintenance. Special attention
physiologic care of the patient. is required when the infant or child is comatose or cannot
respond regarding sensations, especially for pressure areas, heat,
or cold.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Obtain a thorough obstetric history, including previous Provides essential database needed to plan for effective
occurrences of fetal demise. interventions.
Ascertain whether there were any problems conceiving this
pregnancy or any attempts to terminate this pregnancy.
Assess and record the mothers perception of cessation of fetal
movements.
Monitor and record fetal activity or lack of activity.
Inform the mother and signicant others of antepartal testing
and why it is being ordered, and explain results:
Nonstress testing
Oxytocin (Pitocin) challenge test
Ultrasound
Be considerate and honest in keeping the patient and signicant Promotes trusting relationship, and provides support during a
other(s) informed. Share information as soon as it becomes very difcult time.
available.
Allow the mother and family to express feelings and begin Provides support and care to the patient and family, who are
grieving process. unable to begin real grieving because death is not yet real to
them while they are going through a normal birthing
process.
(continued)
Copyright 2002 F.A. Davis Company
Provide private, quiet place and time for the parents and Provides essential support for the family during time of grief.
family to: Provides reality by letting the parents hold the infant.
See and hold the infant
Take pictures
Provide a certicate with footprints, handprints, lock of hair,
armbands, date and time of birth, weight of the infant, and
name of the infant.
Ask the client whether she has a faith community. Asking about a faith community is less threatening than using the
term religion. The client is more likely to respond.
Contact religious or cultural leader as requested by the mother
or signicant other. Provide for religious practices such as
baptism.
Provide references to supportive groups within community,
such as Resolve with Sharing or Parents of Miscarried Children.
Explain need for autopsy or genetic testing of the infant.
In instances of infertility, assist in realistic planning for future: Provides database that can be used in assisting the couple to cope
Possible extensive testing with situation and initiate realistic planning for the future.
Fear
Economics
Uncertainty
Embarrassment
Surgical procedures
Feelings of inadequacy
Life without children
Adoption
Copyright 2002 F.A. Davis Company
Psychiatric Health
NOTE: It may take clients anywhere from 6 months to a year or more to grieve a loss. This should be
taken into consideration when developing evaluation dates. In a short-stay hospitalization, a reason
-
able set of goals would be to assist the client system in beginning a healthy grieving process. It is also
important to note the anniversary date because grief reaction can be experienced past the 1-year pe
-
riod noted here.
ACTIONS/INTERVENTIONS RATIONALES
Assign the client a primary care nurse, and inform client of this Promotes the development of a trusting relationship.
decision. This nurse must have a degree of comfort in discussing
issues related to loss and grief.
Primary nurse will spend 30 min once a shift with the client Promotes the development of a trusting relationship, and provides
discussing his or her perceptions of the current situation. a supportive environment for the expression of feelings, which
These discussions could include: facilitates a healthy resolution of the loss.
His or her perceptions of the loss
His or her values or beliefs about the lost object
Clients past experiences with loss and how these were
resolved
Clients perceptions of the support system and possible
support system responses to the loss
Primary nurse will schedule 30-min interactions with the client
and support system to assist them in discussing issues related to
the loss and answering any question they might have (note time
and date of this interaction here).
Primary nurse will discuss with the client and family role Anticipatory planning facilitates adaptation.
adjustments and other anticipated changes related to the loss.
If necessary after the rst interaction, primary nurse will
schedule follow-up visits with the client and his or her support
system (note schedule for these interactions here).
Spend [number] minutes (this should begin as 5-min times and Promotes the development of a trusting relationship and the
can increase to 10 min as client needs and unit stafng permit) clients sense of control.
with the client each hour. If the client does not desire to talk
during this time, it can be used to give a massage (backrub) or
sit with the client in silence. Inform the client of these times,
and let him or her know if for some reason this schedule has to
be altered and develop a new time for the visit. Inform the client
that the purpose of this time is for him or her to use as he or she
sees t. The nurse should be seated during this time if he or she
is not providing a massage.
Provide positive verbal and nonverbal reinforcement to Positive reinforcement encourages the behavior and enhances
expressions of grief from both the client and the support system. self-esteem.
This would include remaining with the client when he or she is
expressing strong emotions.
Once the client and the support system are discussing the loss, Facilitates healthy resolution of the loss.
assist them in scheduling time when they can be alone with the
client.
Answer questions in an open, honest manner. Promotes the development of a trusting relationship, and promotes
the clients sense of control.
If the client expresses anger toward the staff and this anger Expression of anger is a normal part of the grieving process, and it
appears to be unrelated to the situation, accept it as part of the is safer to be angry with members of the health care team than
grieving process and support the client in its expression by: with the family.
Not responding in a defensive manner
Recognizing the feelings that are being expressede.g., It
sounds like you are very angry right now, or It can be very
frustrating to be in a situation where you feel you have little
control.
Recognize that the stages of grief progress at individual rates Supports the clients perception of control and strengths.
and in various patterns. Do not force a client through stages
or express expectations about what the normal next step
should be.
(continued)
Copyright 2002 F.A. Davis Company
gone.)
transportation
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Provide information to the patient regarding what is occurring This intervention is viewed by survivors as especially helpful
and expected or anticipated changes. during the dying process.29
(continued)
Copyright 2002 F.A. Davis Company
Home Health
See Psychiatric Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention.
symptoms of anticipatory grief:
Crying, sadness
Alterations in eating and sleeping patterns
Developmental regression
Alterations in concentration
Expressions of distress at loss
Denial of loss
Expressions of guilt
Labile affect
Grieving beyond expected time
Preoccupation with loss
Hallucinations
Violence toward self or others
Delusions
Prolonged isolation
Involve the client and family in planning and implementing Family involvement in planning enhances effectiveness of plan.
strategies to reduce or cope with anticipatory grieving:
Family conference: Develop list of concerns and problems;
identify those concerns that family can control.
Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior and lifestyle are facilitated by
required: knowledge and support.
Providing realistic hope
Identifying expected grief pattern in response to loss
Recognizing variety of accepted expressions of grief
Developing and using support networks
Communicating feelings
Providing a safe environment
Therapeutic use of denial
Identifying suicidal potential or potential for violence
Therapeutic use of anger
Exploring meaning of situation
Stress reduction
Promoting expression of grief
Decision making for future
Promoting family cohesiveness
Assist the client and family to set criteria to help them determine Provides data for early intervention.
when intervention of health care professional is requirede.g.,
if the client is threat to self or others, or if the client is unable to
perform activities of daily living.
Consult and/or refer to assistive resources as indicated. Utilization of existing services is efcient use of resources.
Self-help groups, religious counselor, or psychiatric nurse
clinician can enhance the treatment plan.
Copyright 2002 F.A. Davis Company
Grieving, Anticipatory
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., has identified Reassess using initial assessment factors.
support systems of in-laws, sister,
longtime family friend, church
pastor, and Sunday School teacher;
all have been in to visit and indicated
willingness to be of assistance; all
have attended session with nurse
thanatologist. Record RESOLVED. No Is diagnosis validated?
Delete nursing diagnosis, expected
outcome, target date, and nursing
actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
For this diagnosis, the Psychiatric Health nursing actions serve as the generic actions. Please see Psychiatric
Health nursing actions.
Copyright 2002 F.A. Davis Company
Child Health
NOTE: It is difcult to make general assumptions as to how each child views death, but according to
previous patterns of behavior, including communication, it would be necessary to allow for develop-
mental patterns previously attained. In young children, there may be manifestations of obsessive, rit-
ualistic behavior related to the loss or activities surrounding loss. For example, if a loved one died,
young children may think that if they fall asleep they may also die. In the event of grieving, regardless
of the precipitating event, the child must be allowed to respond in keeping with developmental ca-
pacity. At times when the child is in danger of self-injury or injuring others, the risk for violence must
be considered.
ACTIONS/INTERVENTIONS RATIONALES
Provide opportunities for expression of feelings related to loss or Expression of feelings helps deal with sense of loss and provides a
grief according to developmental capacity, e.g., puppets or play database for intervention. Expression of grief reduces uncontrolled
therapy for toddlers. outbursts.
In the event of a family members death, offer support in Provides database for more accurate intervention in dealing with
understanding the deceased family members relationship to the loss.
patient and status for the family, with special attention to
siblings and their reactions. Identify impact grief has for family
dynamics via monitoring of family dynamics.
Allow for cultural and religious input in plan of care, especially Demonstrates valuing of these beliefs to the family, and decreases
related to care of the dying patient and care of the patient at stress for the family.
time of death.
Collaborate with professionals and paraprofessionals to aid in Collaboration offers the most comprehensive plan of care and
resolution of grief according to family preferences. avoids fragmentation of care.
Identify support groups to assist in resolution of grief, such as Support groups offer validation of feelings and a sense of hope as
Compassionate Friends Organization. similar concerns are shared.
Assist the family members in identication of coping strategies Provides for support during the adjustments that are required
needed for resultant role-relationship changes. because of the loss of a loved one.
Assist the family members to resolve feelings of loss via Reminiscing and valuing past experiences will offer an
reminiscing about loved one, positive aspects of situation, or opportunity to project the impact for the present and future.
personal growth potential presented. Remember that behavior
often serves as the most effective communication for the child
or young toddler. .
Allow the family members time and space to face reality of Time and readiness promote the willingness to discuss feelings
situation and ponder meaning of loss for self and the family. after the major emotional shock has diminished.
Direct the family to appropriate resources regarding positive A sense of fulllment may be derived from the sharing of time,
methods of acknowledging loved one through memorials or talent, or money in honor of the loved one. This affords some
related processes. sense of resolve of the guilt or emptiness associated with the loss.
Assist in referral to appropriate resources for funeral planning In times of emotional duress, objective decisions may be difcult.
and arrangements if needed. Providing assistance will offer empowerment and a sense of coping.
In the event of SIDS, provide an opportunity, through a
scheduled conference, for verbalization of:
How the infants death occurred
Police investigation
Sense of guilt
Feelings of powerlessness
Questions
Anger
Disbelief
Fears for future pregnancies and birth
Identify the impact the death or grief has on other family Provides the essential database that can assist in planning that will
members, the relationship of the couple, and the couples offset the development of dysfunctional grieving.
attitude toward having other children.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Schedule a 30-min daily conference with the couple and focus on: Initiates expression of emotions that allows gradual transference
Expression of grief, anger, guilt, or frustration through the grief process. Allows Clarication of issues related to
Exploring expectations regarding children, e.g., the couples a pregnancy that has not resulted in a healthy infant.
expectations, relatives expectations, and societys expectations
(continued)
Copyright 2002 F.A. Davis Company
other
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor source of the interference with the grieving process. Early recognition and intervention can facilitate the grieving
process.
Monitor the clients use of medications and the effects this may Sedatives and tranquilizers may delay the grieving process.
have on the grieving process. Consult with physician regarding
necessary alterations in this area.
Assign a primary care nurse to the client. Facilitates the development of a trusting relationship.
Provide a calm, reassuring environment. Excessive environmental stimuli can increase the clients confusion
and disorganization.
When the client is demonstrating an emotional response to the Encourages appropriate expression of feelings.
grief, provide privacy and remain with the client during this
time.
Primary nurse will spend 15 min twice a day with the client at Facilitates the development of a trusting relationship. Rituals are
[times]. These interactions should begin as nonconfrontational most helpful in situations where there is confusion because of
interactions with the client. The goal is to develop a trusting incompatible demands.14
relationship so the client can later discuss issues related to the
grieving process. If the client and support system do not identify
rituals that would facilitate the grieving process, assist them in
developing rituals as appropriate. Note here the rituals and any
assistance needed in completing the ritual.
Monitor level of dysfunction, and assist the client with activities Facilitates the development of a trusting relationship.
of daily living as necessary. Note type and amount of assistance
here.
Monitor nutritional status, and refer to Imbalanced Nutrition Alterations in nutrition can impact coping abilities, or diminished
(Chap. 3) for detailed care plan. coping abilities can lead to alterations in nutrition.
Monitor signicant others response to the client, and have Support system understanding facilitates the maintenance of new
primary nurse set a schedule to meet with them and the client behaviors after discharge.
every other day to answer questions and facilitate discussion
between the client and the support system. Note schedule for
these meetings here.
Provide the spiritual support that the client indicates is necessary. Clients may nd answers to their questions about life and loss
Note here the type of assistance needed from the nursing staff. through spiritual expression.
Allow the client to express anger, and assure him or her that you Violent behavior can evolve from unexpressed anger. Appropriate
will not allow harm to come to anyone during this expression. expression of anger promotes the clients sense of control and
enhances self-esteem.
Provide the client with punching bags and other physical activity Assists the client in developing appropriate coping behaviors
that assists with the expression of anger. Note tools preferred by enhancing self-esteem.
this client here. Note the specic activities that assist this client
with this expression here.
Remind the staff and support system that the clients expressions Support system understanding facilitates the maintenance of new
of anger at this point should not be taken personally even though behaviors after discharge.
they may be directed at these persons.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those given in Psychiatric
Health.
Home Health
See Psychiatric Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention.
symptoms of dysfunctional grief:
Crying or sadness
Alterations in eating and sleeping patterns
Developmental regression
Alterations in concentration
Expressions of distress at loss
Denial of loss
Expressions of guilt
Labile affect
Grieving beyond expected time
Preoccupation with loss
Hallucinations
Violence toward self or others
Delusions
Prolonged isolation
Involve the client and family in planning and implementing Family involvement in designing the plan of care enhances the
strategies to reduce or cope with dysfunctional grieving: effectiveness of the interventions.
Family conference: Identify concerns.
Mutual goal setting: Set realistic goals with evaluation criteria.
Specify activities for each family member.
Communication: Provide open and honest communication
with positive feedback. Recognize that anger is common and
should not be taken personally.
Assist the client and family in lifestyle adjustments that may be Dysfunctional grieving can be a chronic condition. Permanent
required: changes in behavior and family roles require support.
Providing realistic hope
Identifying expected grief pattern in response to loss
(continued)
Copyright 2002 F.A. Davis Company
Communicating feelings
Stress reduction
Assist the client and family to set criteria to help them Provides for early recognition and intervention.
determine when intervention of health care professional is
requirede.g., prolonged inability to complete activities of
daily living, or threat to self or others.
Consult with or refer to assistive resources as indicated. Psychiatric nurse clinician and support groups can enhance the
treatment plan.
Copyright 2002 F.A. Davis Company
Grieving, Dysfunctional
FLOWCHART EVALUATION: EXPECTED OUTCOME
Can the patient identify at least X number of ways to cope with grief?
Yes No
Record data, e.g., has joined Reassess using initial assessment factors.
Compassionate Friends and
attended two sessions; has
identified two support systems.
Record RESOLVED. Delete
nursing diagnosis, expected
outcome, target date, and
nursing actions. No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
1. Physical barriers
2. Anxiety associated with the parent role
3. Substance abuse EXPECTED OUTCOME
4. Premature infant, ill infant, or child who is unable to effectively ini-
tiate parental contact as a result of altered behavioral organization Will show [number] percent decrease in risk factors by [date].
5. Lack of privacy
6. Inability of parents to meet personal needs TARGET DATES
7. Separation
This diagnosis will require time periods that are longer than those
for other diagnoses to reduce the risk factors. An appropriate initial
RELATED FACTORS8 target date would be 5 to 7 days.
The risk factors also serve as the related factors.
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Make arrangement, when possible, for the patient to interact with Gives opportunity to practice parenting skills and obtain feedback
the infant or child. Accompany the patient to cafeteria, chapel, or in a supportive environment.
visitors lounge. Provide protection for the infant or child. Provide
privacy, but remain close at hand during parent-child interactions.
Encourage the patient with substance-abuse problem to seek Provides long-term support and assistance.
counseling, treatment, and support groups; initiate referrals as
needed.
Encourage time line planning to provide time for care of the Helps the patient not to get overwhelmed with activities needed to
infant or child as well as time for self. care for the infant or child.
Encourage the patient to trade skills or barter for babysitting Provides time for self. Can increase the patients self-esteem
respite. knowing that he or she has skills that can be traded.
Allow the patient to talk about anxiety with parenting. Teach Provides alternate strategies for coping.
stress management and alternate coping strategies.
Have child health clinical nurse specialist or pediatric nurse Provides knowledge base, and helps the patient know that some
practitioner teach parenting skills and growth and development of the things he or she is experiencing are normal.
of premature infant.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors regarding the infant that contribute to or A thorough assessment of reciprocal behaviors will serve as a guide
inuence maternal or paternal or parent or infant reciprocity: to specic needs of parental-infant dyad.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
PREGNANCY
Encourage the expectant parents to discuss their perceptions Allows expectant parents to progress through pregnancy in a
and expectations of the pregnancy. satisfactory and satisfying manner. Provides knowledge base, and
helps the parents know that what they are experiencing is normal.
Provide a nonthreatening atmosphere to encourage the parents
to discuss their fears and concerns.
Assist the parents to dispel myths about birth, postpartum
period, and early parenthood.
Assist the parents to plan for changes in nancial requirements
of pregnancy, birth, and early parenthood.
Encourage the parents to talk to the fetus, spend time together
feeling the fetus move, etc.
Encourage attendance in various classes that can assist in the
transition to parenthood.
Assist the parents in identifying community resources available
to expectant and new parents.
PARENTHOOD30,31
Encourage the new parents to touch, talk to, and observe the Allows expectant parents to progress through pregnancy in a
newborn as soon as possible (immediately is best). satisfactory and satisfying manner. Provides knowledge base, and
helps the parents know that what they are experiencing is normal.
Encourage comparison of newborn characteristics to fantasized
newborn.
Psychiatric Health
This diagnosis is more appropriate under Child Health.
Gerontic Health
This diagnosis is not appropriate to use with gerontic clients.
Copyright 2002 F.A. Davis Company
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention.
strategies to decrease or prevent alterations in attachment:
Identify family strengths and weaknesses.
Design strategies to support strengths and correct
weaknesses.
Yes No
Record data, e.g., state Have Reassess using initial assessment factors.
arranged better schedule for
work and infant care. Now
know how to care for baby.
Risk factors now reduced to
onelack of privacy (live
with husbands parents).
Record RESOLVED. Delete No Is diagnosis validated?
nursing diagnosis, expected
outcome, target date, and
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 561
c. Lack of knowledge about parenting skills
Parenting, Impaired, Risk for and Actual, d. Poor communication skills
and Parental Role Conict e. Preference for physical punishment
f. Inability to recognize and act on infant care
DEFINITIONS8 g. Low cognitive functioning
Risk For Impaired Parenting Risk for inability of the primary h. Lack of knowledge about child health maintenance
caretaker to create, maintain, or regain an environment that pro- i. Lack of knowledge about child development
motes the optimum growth and development of a child.* j. Lack of cognitive readiness for parenthood
3. Physiologic
Impaired Parenting Inability of the primary caretaker to create, a. Physical illness
maintain, or regain an environment that promotes the optimum 4. Infant or Child
growth and development of a child.* a. Multiple births
Parental Role Conict Parent experience of role confusion and b. Handicapping condition or developmental delay
conict in response to crisis. c. Illness
d. Altered perceptual abilities
e. Lack of goodness of t (temperament) with parental ex-
NANDA TAXONOMY: DOMAIN 7ROLE pectations
RELATIONSHIPS; CLASS 1CAREGIVING ROLES, f. Unplanned or unwanted child
AND CLASS 3ROLE PERFORMANCE g. Premature birth
h. Not gender desired
NIC: DOMAIN 5FAMILY; CLASS Z i. Difcult temperament
CHILDBEARING CARE j. Attention decit hyperactivity disorder
NOC: DOMAIN VIFAMILY HEALTH; CLASS X k. Prolonged separation from parent
FAMILY WELL-BEING l. Separation from parent at birth
5. Psychological
a. Separation from infant or child
DEFINING CHARACTERISTICS8 b. High number of or closely spaced children
c. Disability
A. Risk for Impaired Parenting (Risk Factors)
d. Sleep deprivation or disruption
1. Social
e. Difcult labor and/or delivery
a. Marital conict and/or declining satisfaction
f. Young ages, especially adolescent
b. History of being abused
g. Depression
c. Poor problem-solving skills
h. History of mental illness
d. Role strain or overload
i. Lack of, or late, prenatal care
e. Social isolation
j. History of substance abuse or dependence
f. Legal difculties
B. Impaired Parenting
g. Lack of access to resources
1. Infant or child
h. Lack of value of parenthood
a. Poor academic performance
i. Relocation
b. Frequent illness
j. Poverty
c. Runaway
k. Poor home environment
d. Incidence of physical and psychological trauma or abuse
l. Lack of family cohesiveness
e. Frequent accidents
m. Lack of or poor parental role model
f. Lack of attachments
n. Father of child not involved
g. Failure to thrive
o. History of being abusive
h. Behavioral disorders
p. Financial difculties
i. Poor social competence
q. Low self-esteem
j. Lack of separation anxiety
r. Unplanned or unwanted pregnancy
k. Poor cognitive development
s. Inadequate child care arrangements
2. Parental
t. Maladaptive coping strategies
a. Inappropriate child care arrangements
u. Lack of resources
b. Rejection or hostility to child
v. Low socioeconomic class
c. Statements of inability to meet childs needs
w. Lack of transportation
d. Inexibility to meet needs of child or situation
x. Change in family unit
e. Poor or inappropriate caretaking skills
y. Unemployment or job problems
f. Frequently punitive
z. Single parent
g. Inconsistent care
aa. Lack of social support network
h. Child abuse
bb. Inability to put childs needs before own
PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 563
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Provide information relative to normal growth and development Provides knowledge base, and assists the patient to know that
of self and the child by sitting and talking with the patient for some of the things he or she is experiencing are normal.
30 min twice a day at [times].
During conference time, assist the parent to recognize when Prevents a crisis situation. Promotes self-knowledge.
stress is becoming distress, e.g., irritability turns to rage and/or
verbal or physical abuse, sleeplessness, disturbed thought
process, or tunnel perception of situation.
Teach stress management and parenting techniques, e.g., Provides alternative strategies for coping, and provides database
relaxation, deep breathing, Mothers Day Out, safety precautions, needed for dealing with growth and development of the child.
or toileting process.
Provide opportunities for the parent to participate in the childs Gives opportunity to practice parenting skills and obtain feedback
care. in supportive environment.
Discuss disciplinary methods other than physical, e.g., Physical discipline can lead to abuse; sends wrong message to the
grounding, taking away privileges, positive reinforcement, and child.
verbal praise for good behavior.
Encourage the patient to allow time for own needs. Own needs must be met to decrease stress and facilitate meeting
needs of others.
Encourage use of support groups. Initiate referrals as needed. Provides an outlet for the parents with other parents in similar
situations. Provides long-term support and assistance.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Review current level of knowledge regarding parenting of the Provides database needed to more accurately plan care.
infant or child to include:
Parental perception of the infant or child
Parental views of expected development of the infant or child
Health status of the infant or child
Current needs of the infant or child
Infant or child communication (remember, behaviors reveal
much about feelings)
Infants or childs usual responsiveness
Family dynamics, e.g., who offers support for emotional
needs or the childs view of mother and father
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient, through monthly conferences, in completing Acceptance of pregnancy and working through the tasks of
the tasks of pregnancy by encouraging verbalization of: pregnancy provide a strong basis for positive parenthood and
Fears appropriate attachment and bonding.
Mothers perception of marriage
Mothers perception of child within her
Mothers perception of the changes in her life as a result of
this birth:
(1) Relationship with partner
(2) Relationship with other children
(3) Effects on career
(4) Effects on family
Allow the mother to question pregnancy: Now and
Who, me?31
Assist the mother in realizing existence of the child by Provides basis for appropriate attachment behaviors and coping
encouraging the mother to: skills for transition to maternal role.
Note when the infant moves.
Listen to fetal heart tones during visit to clinic.
Discuss body changes and their relationship to the infant.
Verbalize any questions she may have.
Assist in preparation for birth by:
Encouraging attendance at childbirth education classes
Providing factual information regarding the birthing
experience
Involving signicant others in preparation for birthing
process
Assist the patient in preparing for role transition to parenthood
by encouraging:
Economic planning, e.g., physician, hospital, or prenatal
testing fees
Social planning, e.g., changes in lifestyle
(continued)
Copyright 2002 F.A. Davis Company
PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 565
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient in identifying needs related to the familys Assists in identifying patients at high risk for the development of
acceptance of the newborn: this diagnosis.
Mothers perceived level of support from family members
Stressors present in the family, e.g., economics, housing, or
level of knowledge regarding parenting
Monitor for following behaviors:
Refuses to plan for the infant
No interest in pregnancy or fetal progress
Overly concerned with own weight and appearance
Refuses to gain weight (diets during pregnancy)
Negative comments about What this baby is doing to me!
POST PARTUM
Assist the patient and signicant others in establishing realistic
goals for integration of the baby into the family.
Provide positive reinforcement for parenting tasks: Promotes realistic planning for the new baby as well as bonding
Encourage use of birthing room: Labor, delivery, and recovery and attachment.
(LDR) room and labor, delivery, recovery, and postpartum
(LDRP) roomsfor birth to allow active participation in birth
process by both parents.
Allow the mother and partner time with the infant (do not
remove to nursery if stable) following delivery.
Provide mother-baby care to allow maximum continuity of
mother-infant contact and nursing care.
Assist the parents in identifying different kinds of infant behavior Provides the parents with essential information they need to care
and understanding how they allow the infant to communicate for the infant.
with them:
Perform gestational age assessment with the parents, and
explain signicance of ndings.
Perform Brazelton neonatal assessment with the parents, and
explain signicance of ndings.
Demonstrate how to hold the infant for maximum
communication.
Explain infant reexese.g., rooting or Moroand the
importance of understanding them.
Assist the parents in identifying support systems:
Friends from childbirth classes
Parents and parents-in-law
Siblings
Nurse specialists
Encourage the parents to reminisce about birthing experience.
Assist the patient in identifying needs related to family Provides database needed for planning to offset factors that would
functioning: result in ineffective parenting.
Identify negative maternal behavior:
No interest in the new baby
Talks excessively to friends on telephone
Is more interested in TV than in feeding the infant
Refuses to listen to infant teaching
Asks no questions
Extraordinary interest in self-appearance:
(1) Severe dieting to gain prepregnancy gure
(2) Overutilization of exercise to gain prepregnancy gure
Crying, moodiness
Lack of interest in the family and other children
Failure to perform physical care for the infant
Noncompliance: Breaks appointments with health care
providers for self and the infant
Identify negative paternal behavior:
Refusal to support wife by:
(1) Not assisting in child care
(2) Not sharing household tasks
(3) Keeping his social contacts and going out while the
wife remains at home with the child
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the degree to which drugs and alcohol interfere with Early intervention and treatment increase the likelihood of a
the parenting process. If this is a factor, discuss a treatment positive outcome.
program with the client.
Ask the client who is caring for the children while he or she is Early intervention and treatment increase the likelihood of a
hospitalized, and assess his or her level of comfort with this positive outcome.
arrangement. If a satisfactory arrangement is not present, refer
to social services so arrangements can be made.
Discuss with the client expectations and problem perception. Promotes the clients sense of control.
Have the client identify support systems, and gain permission to Support system understanding facilitates the maintenance of
include these persons in the treatment plan as necessary. This behaviors after discharge.
could include spouse, parents, close friends, etc.
If the client desires to maintain parenting role, arrange to have A continuous relationship between the parent and the child is
the children visit during hospitalization. Assign a staff member necessary for the normal development of the child.32
to remain with the client during these visits. The staff person
can serve as a role model for the client and facilitate
communication between the child and the client. Note schedule
for these visits here and the staff person responsible for the
supervision of these interactions.
Answer the clients questions in a clear, direct manner. Promotes the development of a trusting relationship.
Spend 15 min twice a day at [times] with the client discussing Promotes the development of a trusting relationship, and provides
his or her perception of the parenting role and his or her information abut the clients worldview that can be utilized in
expectations for self and the children. constructing interventions.
Arrange 30 min a day for interaction between the client and one Supports the maintenance of these relationships, and provides
member of the support system. A staff member is to be present opportunities for the nurse to do positive role modeling.
during these interactions to facilitate communication and focus
the discussion on parenting issues.
Provide the client with information on normal growth and Provides information that will assist the client in making
development and normal feelings of parents. Provide the client appropriate parenting decisions, enhancing self-esteem. Provides
with concrete information about building age-appropriate parents with specic strategies for afrmation of parent and child
developmental assets. This could include setting appropriate interactions that support positive child development.
boundaries, providing appropriate support, and constructive
use of time.33
Assist the client in developing a plan for disciplining the children. Facilitates the development of positive coping behaviors, and
This plan should be based on behavioral interventions, and the promotes a positive expectational set.
primary focus should be on positive social rewards.33
Teach the client ways of interacting with the child that reduce Promotes positive orientation and enhances self-esteem.
levels of conict, e.g., providing the child with limited choices,
spending scheduled time with the child, and listening carefully
to the child.
Encourage the client to maintain telephone contact with the Assists in maintaining these important relationships to make the
children by providing a telephone and establishing a regular transition home easier.
time for the client to call home or have the children call the
hospital.
Encourage the support system to continue to include the client Assists in maintaining the clients role functioning, thus enhancing
in decisions related to the children by having them bring up self-esteem.
these issues in daily visits and by assisting the client and the
support system to engage in collaborative decision making
regarding these issues.
(continued)
Copyright 2002 F.A. Davis Company
PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 567
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Have the client identify parenting models, and discuss the effect
these persons had on their current parenting style.
Observe interaction between the parents to assess for problems Children can be triangled into parental conicts in an unconscious
in the husband-wife relationship that may be expressed in the effort to preserve the marital relationship.34,35
parenting relationship. If this appears to be happening, refer the
parents to family therapy.
Have the client develop a list of problem behavior patterns, and Promotes the clients sense of control, and begins the development
then assist him or her in developing a list of alternative behavior of alternative, more adaptive coping behaviors.
patterns. For example, Current: When I get frustrated with my
child, I spank him with a belt. New: When I get frustrated with
my child, I arrange to send him to the neighbors for 30 min
while I take a walk around the block to calm down.
Role-play with the client those situations that are identied as Behavioral rehearsal provides opportunities for feedback and
being most difcult, and provide opportunities to practice more modeling of new behaviors by the nurse.
appropriate behavior. This should be done daily in 30-min time
periods. Note schedule for this activity here, list time periods,
and list those situations that are to be practiced. It would be
useful to include spouse.
Have the client attend group sessions where feelings and thoughts Assists the client to experience personal importance to others,
can be expressed to peers and the thoughts and feelings of peers while enhancing interpersonal relationship skills. Increasing these
can be heard. Note schedule for the group here. competencies can enhance self-esteem and promote positive
orientation.
Assist the client in identifying personal needs and in developing Assists the parents to develop strategies for coping with role strain.
a plan for meeting these needs at home; e.g., the parents will
exchange babysitting time with neighbors so they can have an
evening out once a month. Note this plan here.
Monitor staff attitudes toward the client, and allow them to Negative attitudes of staff can be communicated to the client,
express feelings, especially if child abuse is an issue with this decreasing the clients self-esteem and increasing the clients
client. defensiveness.
Assist the client with grieving separation from the child, and
refer to Anticipatory Grieving for detailed nursing actions.
Provide the client with positive verbal support for positive Positive reinforcement encourages behavior and enhances
parenting behavior and for progress on behavior change self-esteem.
goale.g., You demonstrate a great deal of concern for your
childs welfare, or You have taught your child to be very
sensitive. Make sure these comments are honest and t the
clients awareness of the situation.
Assist the client in developing stress reduction skills by:
Teaching deep muscle relaxation and practicing this with the
client 30 min a day at [time].
Discussing with the client the role physical exercise plays in
the client during these exercise periods. Note time for these
periods here.
Gerontic Health
NOTE: This would be an unusual diagnosis for the gerontic patient, but might develop if the grand-
parents had to take grandchildren into their home as a result of a family crisis. In that instance, the
nursing actions would be the same as those given in Adult Health and Child Health.
Copyright 2002 F.A. Davis Company
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Act as role model through use of positive behaviors when Role modeling provides example for parenting skills.
interacting with the child and parents.
Report child abuse and neglect to the appropriate authorities. Meets legal requirements and provides for intervention.
Teach the client and family appropriate information regarding Knowledge is necessary to provide appropriate child care.
the care and discipline of children:
Cultural norms
Normal growth and development
Anticipatory guidance regarding psychosocial, cognitive, and
physical needs for children and parents
Expected family life cycles
Development and use of support networks
Safe environment for family members
Nurturing environment for family members
Special needs of the child requiring invasive or restrictive
treatments
Involve the client and family in planning and implementing Involvement of the family in planning enhances the effectiveness
strategies to decrease or prevent alterations (risk for or actual) of the interventions.
in parenting:
Family conference: Identify each members perspective of the
situation.
evaluation criteria.
positive feedback.
Assist the client and family in lifestyle adjustments that may be Long-term behavioral changes require support.
required:
Development of parenting skills
Use of support network
Establishment of realistic expectations of the children and
spouse
Refer to appropriate assistive resources. Support groups, family therapist, school nurse, and teachers can
enhance the treatment plan.
Copyright 2002 F.A. Davis Company
PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 569
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage verbalization of feelings, both positive and negative, Brings feelings out into the open, and claries emotions and
by actively listening, using reection, asking open-ended makes them easier to cope with.
questions, etc., about relocation. Schedule 30 min twice a day
at [times] to focus on this topic.
Determine any previous experience with relocation and the Provides understanding of problem and information to further
strategies used to cope with the experience during discussions develop interventions. Determines previously used coping
with the patient. strategies, which ones were successful or unsuccessful, and what
alternative strategies may be tried.
Allow the patient to control, to the extent possible, his or her Increases self-condence, and decreases feeling of powerlessness.
environment.
Provide consistency in daily care, such as same primary nurse, Provides security, thus facilitating adjustment.
same daily routines, and same environment.
Explain all procedures prior to implementation. Decreases anxiety.
Teach stress management techniques such as relaxation, Decreases anxiety so that energy can be used to implement
meditation, deep breathing, exercise, or diversional activities. effective coping strategies.
Have the patient return-demonstrate technique for 15 min
twice a day at [times].
Consult with other health care professionals as necessary. Collaboration promotes care that incorporates physiologic and
psychosocial interventions that may be needed as a result of
relocation stress.
Help the patient maintain former relationships by providing Decreases feelings of isolation and depression.
letter-writing materials or a telephone.
Provide the patient with a list of organizations and community Assists the patient to develop new relationship and may hasten
services available for newcomers, e.g., Welcome Wagon, senior adjustment.
citizens groups, churches, or singles groups.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Assess, to the degree possible, the emotional stability of the Adaptability to change is determined to a large degree by
patient and family (can use Chess-Thomas Temperament temperament and previous coping.
Scale36).
Schedule a family conference of at least 1 h daily and focus on: Provides support to cope with changes caused by relocation.
Feelings of the patient and family regarding move
Aspects of relocation that are problematic, e.g., school or
friends
might offer
Womens Health
The nursing actions for a woman with this nursing diagnosis are the same as those found in Adult Health
and Gerontic Health.
Psychiatric Health
In addition to those interventions identied under Adult Health and Gerontic Health, the following in-
terventions apply.
ACTIONS/INTERVENTIONS RATIONALES
Assess the clients cognitive resources. Nursing interventions should be adapted to the clients cognitive
abilities.37
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
NOTE: These actions apply to the patient entering an acute care facility.
ACTIONS/INTERVENTIONS RATIONALES
Identify whether the patient is at risk for relocation syndrome. Early identication of patients at risk can mean earlier intervention
In older adults, this may include those with no condant (social and a possible decrease in the negative consequences of relocation.
support), those who perceive themselves as worriers, those in
poor health, and those with low self-esteem.38
Assist the patient in realistic perception of event: What has May assist in accepting need for relocation.
occurred, reasons for transfer based on physical needs, changed
health status.
Provide supportive care as the situation requires, such as Allows responses that are tailored to the individuals expressed
answering questions regarding the routines in the hospital or needs.
expected course of treatment.
Discuss possible occurrence of syndrome with signicant others. Provides anticipatory information that avoids undue stress on the
family.
Discuss with the patient and signicant others the patients Provides database to build on prior to discharge from acute care
usual coping skills. facility.
Discuss transfer with the patient and family. Provides time to question and to promote positive adjustment to
the change in location.
If not returning to prehospitalization location, discuss with the Allows time for ventilation of feelings related to the relocation.
patient his or her proposed plans, reasons for transfer, and the
patients response to proposal.
Home Health
See Psychiatric Health for additional interventions.
ACTIONS/INTERVENTIONS RATIONALES
Assist the client or caregiver to make the new environment as Enhances the clients sense of security and comfort.
much like the previous environment as possible:
Similar schedules and routines
Decorations from previous environment
Signicant items such as blankets, artwork, and music
Foods served should be as familiar as possible.
Educate the client or caregiver as far in advance as possible of Promotes a sense of control, and avoids unpleasant surprises.
necessary changes in location, and tell them what to expect.
When the change in location involves separation from signicant Enhances the clients sense of security and comfort.
others, help the client or caregiver to obtain items that may
increase the clients comfort:
Photographs of loved ones
Letters and cards from loved ones
Videotapes and/or audiotapes of loved ones
Copyright 2002 F.A. Davis Company
and Actual
Yes No
Record data, e.g., states has Reassess using initial assessment factors.
found some people to play
bridge; likes exercise program
here and independence allowed;
Its really not bad at all;
Im having a good time.
Record RESOLVED. Delete
nursing diagnosis, expected No Is diagnosis validated?
outcome, target date, and
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the patient to express his or her perception of role Relieves stress, and helps the patient clarify feelings in a safe
responsibilities by active listening, using reection, asking environment.
open-ended questions, accepting the patients feelings, and
maintaining a nonjudgmental attitude.
Help the patient and signicant others realistically negotiate role Facilitates problem solving. Promotes cooperation among involved
responsibilities by assisting in the problem-solving process persons.
What is the role? What are its responsibilities? How can
responsibilities be shared? What outcomes are expected of
the role? Have the patient and signicant other(s) meet together
for 1 h every other day.
Teach the patient regarding role, e.g., parent, caregiver, or Claries misconceptions, and provides realistic role expectations.
breadwinner. Allow time for discussion, return-demonstrations,
and questioning prior to discharge.
Help the patient identify community resources to assist in role Provides support for short-term and long-term problem solving.
responsibilities prior to discharge.
Refer to psychiatric nurse clinician as needed (see Collaboration promotes holistic plan of care, and problem may
Psychiatric Health nursing actions for more detailed need specialized interventions.
interventions).
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Determine how the child and parent perceive the expected role Provides essential database necessary to plan care.
for the child.
Identify confusion or diffusion of role according to the childs Problem identication serves to establish common areas to be
and parents expectations versus actual role. further explored in role performance.
Determine value the child has in the family. The value a child has for each family is critical to expectations for
all involved.
Determine the childs self-perception. Ones self-perception provides insight into how one evaluates his
or her own performance.
Identify ways to alleviate role performance alteration according Alleviation of one or more role performance alterations may
to actual cause. If child is temporarily unable to participate in prevent further deterioration in role functioning, with a greater
certain physical activities, explore other nonphysical ways the appreciation for the value of all roles.
child can participate.
Allow for ventilation of feelings by the child via puppetry, art, Feelings are most critical in exploring ones role performance.
or other age-appropriate methods. Schedule at least 30 min Appropriate aids in communication serve to foster focused play or
during each 8-h shift, while awake, for this activity. Note times behaviors to reveal thoughts of the child who is unable to express
here. himself or herself.
Provide the patient and parents with options to best facilitate Vicarious involvement allows for shared activities and the sense
needs for future implications of compromised role of maintaining closeness with the desired groups or person.
performancee.g., shared experiences with peers who have
temporarily had to forsake physical activities because of illness.
How did they keep up with the team?
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Allow the patient to describe her perception of her role as a Provides database to initiate care planning.
mother, wife, and working woman.
Identify sources of role stress and strain that contribute to role
conict and fatigue.
Assist in developing a schedule that manages time well, both at
home and at work.
Involve signicant others in planning methods of reducing role Encourages the patient to identify various roles she is currently
stress and strain at home by: fullling, and provides support that allows planning of coping
Assisting with child care strategies and techniques.
Assisting with household duties
Sharing carpooling and childrens activities
Encourage the patient to use time at work for work activities
and time at home for home activitiesi.e., do not take work
home.
Look at possibility of job sharing or part-time employment
while the children are at home.
Plan home activities in advance, such as shopping and cooking
meals in advance and freezing them for later use.
Encourage division of workload by exchanging childcare
activities with friends or other families in the
neighborhood.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Sit with the client [number] minutes [number] times per day to Provides information about the clients perceptions and
discuss the clients feelings about self and role performance. expectations that can be utilized in developing specic
interventions.
Answer questions honestly. Promotes the development of a trusting relationship.
Provide feedback to the client about nurses perceptions of the Assists the client in realistically evaluating his or her perceptions.
clients abilities and appearance by:
Using I statements
Using references related to the nurses relationship to the
client
Describing the nurses feelings in relationship
Provide positive reinforcement. List here those things, including Reinforcement encourages positive behavior and enhances
social rewards, that are reinforcing for the client and when they self-esteem.
are to be used. Also list those things that have been identied as
nonreinforcers for this client.
Provide group interaction with [number] persons [number] Assists the client to experience personal importance to others,
minutes 3 times a day at [times]. This activity should be gradual while enhancing interpersonal relationship skills. Increasing these
within the clients abilitye.g., on admission the client may role competences can enhance self-esteem and promote a positive
tolerate 1 person for 5 min. If the interactions are brief, the orientation.
frequency should be highe.g., 5-min interactions should
occur at 30-min intervals.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the patient how he or she perceives his or her role Provides opportunity to gain the patients exact perspective on
performance has altered. situation. Provides database need for most effective planning.
Discuss with the patient potential role modications or Depending on the patients interests and abilities, these measures
substitutions, such as foster grandparenting, friendly visitor at would provide an alternate method to achieve role satisfaction.
a long-term-care facility, participant in intergenerational
programs, or telephone reassurance visitor or caller.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to disturbed role performance. Provides database for early recognition and intervention.
Involve the client and family in planning, implementing, and Family involvement in planning increases the likelihood of
promoting reduction or elimination of disturbance in role effective intervention.
function:
Family conference: Clarify expected role performance of all
family members.
Assist the client and family in lifestyle adjustments that may be Long-term behavioral changes require support.
required:
Treatment of physical or emotional disability
Stress management
Adjustment to changing role functions and relationships
Development and use of support networks
Requirements for redistribution of family tasks
Consult with assistive resources as indicated. Utilization of existing services is efcient use of resources.
Psychiatric nurse clinician, occupational and physical therapists,
and support groups can enhance the treatment plan.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has requested Reassess using initial assessment factors.
and received orientation to job
status change; husband now
helping with household chores.
Record RESOLVED. Delete
nursing diagnosis, expected
outcome, target date, and
nursing actions. No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the patient to express how he or she feels or what he Assists the patient to examine social experience and verbalize
or she fears in a social situation by scheduling at least 10 min feelings. Encourages therapeutic relationship.
twice a day at [times] to focus on this topic.
Evaluate the patients communication skills, and help him or Improves communication skills.
her to nd alternative ones during interactions with the patient.
Help the patient obtain a realistic perception of self by focusing Helps the patient see that no one is perfect, and improves
on and enhancing strengths during conferences with the patient. self-concept.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for contributory factors to altered social interaction Provides database needed to plan appropriate care.
pattern, e.g., role-play with puppets.
Determine the effect the altered social interaction has on the Provides database needed to accurately plan intervention.
child, parent, family, and school.
Develop a plan of care to best meet the childs potential for Individual family values will dictate the way in which social
succeeding with appropriate social interactionthis will be interaction is dealt with.
impacted by social class and values.
Determine whether conict exists between the parents and the Conict may prevent appropriate attention to actual social
childs desired social interaction. interaction, but must be dealt with as it will remain a critical
component. This may be true particularly at times of authority
issues, e.g., adolescence.
If conict exists regarding social interaction, deal with this as Values and beliefs may be in conict, and some resolution of the
needed in values or beliefs pattern. problem is essential to prevent further long-term effects.
Assist the child, parents, and family in ventilation of feelings Ventilation of feelings and the opportunity to do so serve to value
regarding social interaction impairment, including actual the importance for the patient to help reduce anxiety and initiate
consequences of the impairment. problem resolution.
Make referrals as appropriate to professionals best able to assist Referral serves to best deal with problems according to a match of
in dealing with problem, e.g., psychiatric nurse clinical needs and resources.
specialist, play therapist, or family therapist.
Identify local support groups to appropriately match needs, e.g., Resource groups provide vital support through provision of a
parent-child support groups for the handicapped, United common shared sense of concern, coping, and empowerment.
Cerebral Palsy Association, or Spina Bida Association.
If impaired social interaction also relates to school, include Valuing the importance of school and the need to provide the
teacher and essential school personnel in plans for resolving the best for the child and family in the development of positive
impairment and for best follow-up. social interaction is showing respect for the patient and family.
Identify follow-up appointment needs and ways to monitor Provides reinforcement, and attaches value to follow-up.
progress for the child and familye.g., stickers as incentives to
reinforce desired behavior.
Anticipate discrepant or unrealistic parental expectations of the Unrealistic demands or expectations are risk indicators for abuse.
child. Monitor for potential abuse of the child according to
pattern for this.
Womens Health
This nursing diagnosis will pertain to women the same as to any other adult. The reader is referred to the
other sectionsAdult Health, Child Health, Psychiatric Health, Gerontic Health, and Home Healthfor
specic nursing actions.
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
If delusions or hallucinations are present, refer to Disturbed
Sensory Perception for detailed interventions.
Assign primary care nurse to the client. Promotes the development of a trusting relationship.
Primary nurse will spend [number] minutes twice a day at Promotes the development of a trusting relationship, and provides
[times] with the client. The focus of this interaction will change opportunities for the client to observe the nurse in appropriate
as a relationship is developed. Initially the nurse should model interpersonal interactions.
for the client how to develop a relationship through his or her
behavior in developing this relationship with the client. This
modeling should include demonstrating respect for the client;
consistency in interaction; congruence between thoughts,
feelings, and actions; and empathy.
Have the client identify those persons who are considered Assists the client in reality testing of the belief that he or she is
family, friends, and acquaintances. Then have the client note having difculty with interpersonal relationships.
how many interactions per week occur with each person. Have
the client identify his or her thoughts, feelings, and behavior
about these interactions.
Provide appropriate confrontation with the client about his or Assists the client in developing alternative coping behaviors that
her behavior patterns that inhibit interaction in relationships are adaptive.
with the nurse.14
Observe the client in interactions with others on the unit, and Facilitates the provision of feedback to the client on methods he or
identify patterns of behavior that inhibit social interaction. she could use to improve interpersonal effectiveness.
Develop a list of those things the client nds rewarding, and Positive reinforcement encourages behavior.
provide these rewards as the client successfully completes
progressive steps in treatment plan.
When the client is demonstrating socially inappropriate Continuing the interaction could provide positive reinforcement
behavior, keep interactions to a minimum and escort the and encourage inappropriate behavior.
client to a place away from activities.
When inappropriate behavior stops, discuss the behavior with Promotes the clients sense of control, and begins the development
the client and develop a list of alternative kinds of behavior for of alternative, more adaptive coping behaviors. Social isolation
the client to use in situations where the inappropriate behavior assists in decreasing behaviors.
is elicited. Note here those kinds of behavior that are identied
as problematic, with the action to be taken if they are
demonstratede.g., the client will spend time out in seclusion
and away from group activity.
Develop a schedule for gradually increasing time of the client in Social interaction can provide positive reinforcement and
group activities. For example, the client will spend [number] opportunities for the client to practice new behaviors in a
minutes in the group dining hall during mealtimes or will spend supportive environment.
[number] minutes in a group game. Note the clients specic
activities here.
Primary nurse will spend 30 min a day with the client exploring
thoughts and feelings about social interactions and assisting
with reality testing of social interactione.g., what others might
mean by silence and other nonverbal responses.
Identify with the client areas of social skill decit, and develop Promotes the clients sense of control, and begins the development
a plan for improving these areas. This could include: of alternative, more adaptive coping behaviors by increasing role
Assertiveness training competence.
Role-playing difcult situations
Teaching the client relaxation techniques to reduce anxiety
in social situations (Note here the plan and schedule for
implementation. This should be a progressive plan with
rewards for accomplishment of each step.)
Consult with occupational therapist if the client needs to learn Increasing behavioral repertoire increases role competence, which
specic skills to facilitate social interactionse.g., cooking skills enhances self-esteem.1
so friends can be invited to dinner, or craft skills so the client
can join others in social interactions around these activities.
Include the client in group activities on the unit, and assign the Reinforcement encourages positive behavior and enhances
client activities that can be easily accomplished and that will self-esteem.
provide positive social reinforcement from other persons
involved in the activities.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The 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
Monitor for factors contributing to the impaired social Provides database for early recognition and intervention.
interaction, e.g., psychological, physical, economic, or spiritual.
Involve the client and family in planning, implementing, and Family involvement enhances the effectiveness of the interventions.
promoting reduction or elimination of Impaired Social Interaction:
Family conference: Identify perspective of each member.
Establish consistent rules for behaviors.
Mutual goal setting: Set consistent rules for behavior and provide
Assist the patient and family in lifestyle adjustments that may Permanent changes in behavior and family roles require support.
be required:
Providing safe environment
Development and use of support networks
Change in role functions
Prescribed treatments, e.g., medications or behavioral
interventions
Finances
Stress management
Suicide prevention
Assist the client and family to develop criteria to determine Provides database for early recognition and intervention.
when crisis exists and professional intervention is necessary:
Violence
Sudden change in ability to care for self
Hallucinations or delusions
Consult with or refer to assistive resources as indicated. Utilization of existing services is efcient use of resources. Respite
care and support groups can enhance the treatment plan.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has joined softball Reassess using initial assessment factors.
team and is playing daily in summer;
is enrolling in an art class this fall; has
joined a local hospital volunteer group;
states, Im having a good time and
meeting some new people.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target No Is diagnosis validated?
date, and nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the patient to verbalize feelings of isolation and Promotes a therapeutic relationship where the patient can
aloneness by visiting the patient every hour and scheduling a verbalize feelings in a nonthreatening environment.
discussion for at least 10 min each shift while awake.
Provide positive feedback and support for social interactional Increases self-condence. Decreases anxiety in social situations.
skills as appropriate.
Encourage the patient to use assistive or corrective devices such Increases self-esteem and self-condence.
as articial vocal cord; limb, eye or breast prosthesis; or special
make-up. Have the patient return-demonstrate self-care
management activities at least daily.
Encourage visits from the family and signicant others daily. Increases social contacts and interactional skills.
Encourage the patient to participate in diversional activities, Increases social contacts and interactional skills.
especially those involving groups, daily.
Encourage the patient to identify and use community support Increases social contacts. Promotes assistance with short-term and
systems and groups prior to discharge. long-term goals.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Provide opportunities for expression of feelings about desired Ventilation of feelings allows for insight into the patients thinking
social activity by spending 1520 min per shift, during waking and assists in reducing anxiety.
hours, at [times] with the patient and family.
Determine what obstacles are perceived by the patient and Directed inquiry into obstacles that prevent the patient from
family in pursuit of desired social activities by asking both engaging in desired social interaction increases the likelihood of a
direct and open-ended questionse.g., What do you think more complete database that will allow more individualized
prevents you from doing what you want to? planning.
Identify what realistic patterns for socialization are applicable Realistic goals are more likely to bring about the desired changes
for the patient and family in collaboration with the patient and for more effective social interaction.
family.
Collaborate with other health care professionals to meet realistic Appropriate use of resource personnel ensures optimal likelihood
goals for patient and family socialization. for goal attainment.
Monitor for contributory related factors to best consider social All factors must be considered to provide a holistic plan of care.
activity pattern.
Identify support groups to assist in realization of desired social Support groups provide a sense of sharing and empowerment.
activities.
Monitor the patients and familys perceptions of the effect Roles are closely impacted by patterns of social interaction.
desired social activities might have on current role-relationship
pattern.
Provide appropriate opportunities for assessment of the young The childs view of self in relationship to social patterns is vital to
childs perceptions of situational needs and how he or she planning the most effective interventions.
views self.
Assist the patient to develop schedule for consideration of Appropriate planning serves to increase success with desired
desired social activities at least 2 days before dismissal from activities.
hospital.
Provide for appropriate follow-up appointment as needed Follow-up plans attach value to long-term care for the patient.
before dismissal from hospital.
Womens Health
NOTE: When women experience social isolation, it is especially important to assess for the
presence of domestic violence. Social isolation may be one of the means abusers use to control
his or her partner. The following nursing actions apply to the social isolation experienced by the pa-
tient who has sexually transmitted diseases such as herpes genitalis, syphilis, chlamydia, gonorrhea,
and AIDS.
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
If delusions and/or hallucinations are present, refer to Disturbed Assists in understanding the clients worldview, which facilitates
Sensory Perception for detailed interventions. the development of client-specic interventions.
If social isolation is related to the clients feelings of powerlessness,
refer to Powerlessness (Chap. 8) for detailed interventions.
Discuss with the client his or her perception of the source of the
social isolation, and have him or her list those things he or she
has tried to resolve the situation.
Have the client list those persons who are considered family, Facilitates the clients reality testing of his or her perception of
friends, and acquaintances. Then have the client note how being socially isolated.
many interactions per week occur with each person. Have the
client identify what interferes with feeling connected with these
persons. This activity should be implemented by the primary
nurse. Note schedule for this interaction here.
When contributing factors have been identied, develop a plan Facilitates the development of alternative coping behaviors that
to alter these factors. This could include: enhance role performance.
Assertiveness training
Role-playing difcult situations
Teaching the client relaxation techniques to reduce anxiety in
social situations (Note plan and schedule for implementation
here.)
Develop a list of those things the client nds rewarding, and Reinforcement encourages positive behavior and enhances
provide these rewards as the client successfully completes self-esteem.
progressive steps in treatment plan. This schedule should be
developed with the client. Note here the schedule for rewards
and the kinds of behavior to be rewarded.
Consult with occupational therapist if the client needs to learn Increases the clients competencies, which enhances role
specic skills to facilitate social interactionse.g., cooking skills so performance and self-esteem.
friends can be invited to dinner, craft skills so the client can join
others in social interactions around these activities, or dancing.
Provide the client with those prostheses necessary to facilitate
social interactions, e.g., hearing aids or eyeglasses. Note here the
assistance needed from nursing staff in providing these to the
client. Also note where they are to be stored while not in use.
Include the client in group activities on the unit. Assign the client Successful accomplishment of a valued task can provide positive
activities that can be easily accomplished and that will provide reinforcement, which encourages behavior.
positive social reinforcement from other persons involved in the
activities. This could include things like having the client assume
responsibility for preparing a part of a group meal or for serving
a portion of a meal.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the patient what efforts he or she has made to Assists in determining what interventions may result in positive
increase social contacts and what results have been obtained. outcomes.
Ask the patient to identify hobbies and activities that have been Provides information on preferred activities, and guides the nurse
a part of his or her adult life. in seeking resources that match the patients interests.
Ask the patient to identify barriers to continuing with the Barriers may be indicators of need for use of specic resources
hobbies and activities he or she enjoyed. such as adaptive equipment or transportation.
Assist the patient in identifying and contacting community In many areas, initial contact with support services can entail
support services. numerous telephone calls to reach the appropriate resource.
Home Health
See Psychiatric Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement in planning enhances the effectiveness of
strategies to reduce social isolation: interventions.
Family conference: Discuss perceptions of source of social
isolation, and list possible solutions.
Assist the family and patient with lifestyle adjustments that may Permanent changes in behavior and family roles require support.
be required:
Promote social interaction.
Provide transportation.
Provide activities to keep busy during lonely times.
Provide communication alternatives for those with sensory
decits.
Assist with disguring illnesse.g., refer the patient to
Social Isolation
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
Record data, e.g., is assisting in teaching Reassess using initial assessment factors.
art at community centers; states, really
enjoying making new friends and were
going to a concert Friday night.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target
date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Assess the events that precipitate chronic sorrow and make the Provides information for anticipatory guidance.
patient feel disparity between self and others.
Assess the patients coping methods. Determine what helps Supports the patient, and helps the patient learn effective coping
when the patient feels sorrow. Support the coping strategies methods.
that work, or teach other strategies that may help.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
NOTE: Identify developmentally appropriate approach with incorporation of nursing interventions
that are appropriate.
ACTIONS/INTERVENTIONS RATIONALES
Monitor for all possible contributing factors to chronic sorrow, Provides the most holistic database to offer appropriate
including history, family, child, or others as feasible. individualization.
Encourage the child and family members to verbalize feelings Expression of feelings helps reduce anxiety and offers clues to
about sorrow. related issues.
Identify preferences of the child to further express feelings per Free and creative expression provides a noninvasive insight to
age-appropriate play, art, discussion, or, when appropriate, monitor feelings on an ongoing basis.
support groups.
Help the child and family to identify the meaning the chronic Signicance of sorrow is often the key to acceptance and reducing
sorrow provides. negative effects of sorrow.
Identify ways to cope with factors that contributed or contribute Growth is enhanced when coping strategies familiar to the client
to chronic sorrow by determining previously successful coping are valued.
patterns.
Introduce additional coping strategies according to the childs Reinforcement is best timed when the client is successfully dealing
and familys readiness. with demands and is more likely to accept additional modes.
Determine the effect chronic sorrow has on basic daily Sorrow may be interfering with basic daily activities.
functioning.
Support the childs and familys daily progress in expression of Ongoing assessment and expression foster trust and open
feelings and ways to cope with sorrow. communication.
Identify need for other pediatric specialists as needed, e.g., play Experts will best be able to deal with the childs and familys
therapist, child psychologist, and psychiatrist. long-range needs.
Determine support group for long-term follow-up. Peer support is valued, with likelihood of bonding and reduction
of feelings of isolated sorrow.
Provide sensitive inquiry as related to anniversaries or events Valuing of the importance of events for the child and family
that may hold signicance for the child or family. provides respect and facilitates sharing to foster trust.
Identify, with the childs and familys input, ways to effectively Actual resolution of chronic sorrow is possible with individualized
cope with chronic sorrow. plan known to be effective and familiar to the client, thereby
Womens Health
For this diagnosis, the Womens Health nursing actions are similar to Adult, Children, Gerontic, and Psy-
chiatric Health, except for the following:
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
Obtain from the client or other family members information Some deaths of babies are a relief to the parents, such as in the
about the cause of sorrow that could help with understanding case of congenital abnormalities or a long, difcult illness of a
and, therefore, planning actions to support the client. child. This does not mean they do not love their babies and could
Determine, if possible, the cause of death and the gestational experience feelings of guilt because of the feeling of relief. Many
age of fetus and/or infant at time of death. family members and relatives do not know what to say or do, and
Determine nature of attachment of the parents to the infant. therefore ignore the subject, believing this is better for the parents
Discuss past unresolved grief. so they can forget sooner.
Determine social support of parents. (Beware of a conspiracy
of silence.)42,43
Discuss with the parents the aspect of anniversaries, birthdays, Such dates often become an anticlimax; they have dreaded the date
or holidays. Give suggestions of how to observe the childs and either nd it easy or very difcult. Acknowledgment tells the
memory, such as: parents that you share their pain without becoming intrusive.
Have a small ceremony with the family and friends at Holidays are very difcult, particularly when other children are
gravesite, in home, or place of worship. celebrating. It often becomes a reminder that they will never be
Plant a tree or owers in the childs memory. able to do these things with their child.
Encourage the family and friends to acknowledge awareness
of special day to the parent.
Psychiatric Health
NOTE: Because this is a normal response, clients most likely to have this diagnosis will be seen as out-
patients. Inpatient clients may experience this response if a trigger event occurs during hospitalization.
ACTIONS/INTERVENTIONS RATIONALES
Provide the client with the information he or she requests Assists with decision making and promotes sense of control.44,45
related to illness and disease process.
Sit with the client [number] minutes [number] times a day to Assists with coping, and promotes sense of control.44
explore and provide specic information he or she may need to
cope with the identied situation.
Provide information that indicates to the client that his or her Alleviates feelings of difference or isolation, and increases sense
reaction is normal. This information should be provided in a of control. Assists client in making room for grief, as a normal
manner that does not diminish the individuals personal process, in his or her life.14,45
experience.
Discuss with the client the situations that might contribute to Promotes client understanding of the experience, and assists with
the increase or recurrence of grief feelings. These situations the normalizing of the experience, while providing anticipatory
could include comparisons with norms, management crises, guidance.46 Facilitates the development of the belief that grief is
anniversaries, unending caregiving, and awareness of role a life process and not something that is dealt with or ended.45
changes. Note here the person responsible for this discussion.
Sit with the client [number] minutes [number] times per day to Validates the clients experience, and legitimizes the emotions.14,47
provide an opportunity for him or her to tell his or her story
with the effect of the experience.
Discuss with the client his or her beliefs about grief and how it Understanding the clients perceptions provides the foundation for
affects his or her life. necessary change.45
Discuss with the client previous strategies utilized to cope with Supports strengths, and assists with the development of
loss and the extent to which these were successful. Note here client-specic coping strategies.14,43
the person responsible for this discussion and ongoing follow-up.
Provide the client with necessary supports to utilize identied Facilitates the use of coping strategies.44
coping strategies. Note here those supports, specic for this client,
needed from staff. This could include referrals to community
support groups, arrangements for respite care, supporting the
use of humor and play as a coping strategy, arrangements to
interact with spiritual leader, and providing opportunities for
physical activity.
(continued)
Copyright 2002 F.A. Davis Company
(1) Include open, honest communication about those issues Addressing both the perceived positive and negative aspects of a
the system nds most difcult to discuss. situation opens communication and decreases guilt.45
(2) Provide information the system needs about the situation Promotes sense of control, and facilitates decision making.
and disease process.
Refer support system to community support groups. Normalizes experience, and provides a source for information on
coping.
Discuss opportunities for respite from caregiving Decreases guilt related to the need to withdraw from the
Gerontic Health
In addition to the nursing actions provided here, the nurse is referred to the Psychiatric Health section for
this diagnosis.
ACTIONS/INTERVENTIONS RATIONALES
Provide the client and/or caregiver with information that is Assists the client and/or caregiver to have a sense of control in
understandable, focused on the specic information needed for meeting care needs.
the situation, and practical.
Encourage use of community or facility or web site support Gives the client or caregiver access to information and resources
services dealing with the specic disability or chronic illness that may help meet the challenges of their condition.
involved.48
Promote use of available respite services as needed. Provides a means of positive coping for the individual.
Advise the older adult to maintain personal interests and Identied in research as a means of coping and maintaining
activities as much as possible. control.48,49
Use empathetic presence (listening, offering support and Helps the client or caregiver feel supported by professionals
encouragement and validation of feelings). involved in care needs.
Discuss with the client or caregiver milestones and events that may Presents opportunities for anticipatory guidance.
trigger episodes of feeling sorrow, such as anniversaries, birthdays,
or celebrations that contrast what could have been with what is.46
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Actively listen to the clients story, helping him or her to put There is an almost universal need to describe the feelings and
events in sequence, increasing his or her recall of details, and events of a death or major diagnosis.
separating what is real from what is not.50
Teach the client and signicant others the importance of Removes impediments to healthy expression of sadness.
expressing and accepting sadness:50
Avoid platitudes.
Avoid quiet suffering and suppression of grief.
Change settings as necessary to allow expressions of grief.
Assist the client to acknowledge and express feelings of guilt. This is the rst step in resolution of feelings of guilt.
If the chronic sorrow is related to death, assist the client in Talking about the relationship is an important element of healing.
reviewing his or her relationship with the deceased:50
Exploring the early days of the relationship, covering
negative aspects as well as positive aspects
Exploring what might have been had the death not occurred
Consult with and/or refer the patient to assistive resources as Utilization of existing services is an efcient use of resources.
needed.
Copyright 2002 F.A. Davis Company
Sorrow, Chronic
Is the client expressing less sadness today compared with the day
of admission to services?
Yes No
Record data, e.g., states feeling less Reassess using initial assessment factors.
sadness, is socializing more, and has
identified a support group.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target
date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Maintain a patient, calm approach by: Avoids interfering with the patients communication attempts.
Allowing adequate time for communication
(continued)
Copyright 2002 F.A. Davis Company
head
Anticipating needs
Provide materials that can be used to assist in communication Provides alternative methods of communication. Decreases anxiety
e.g., magic slate, ash cards, pad and pencil, Speak and Spell and feelings of powerlessness and isolation.
computer toy, pictures, or letter board.
Inform the family, signicant others, and other health care Promotes effective communication. Avoids frustration for the
personnel of the effective ways the patient communicates. patient.
Answer call bell promptly rather than using the intercom system. Decreases stress for the patient by not straining communication
resources.
Assure the patient that parenteral therapy does not interfere Decreases anxiety.
with the patients ability to write.
Initiate referral to speech therapist if appropriate. Initial teaching regarding speech may need interventions by specialist.
Initiate referrals to support agencies such as Lost Chord Club or Groups that experienced the same problems can assist in
New Voice Club as appropriate. rehabilitationand decrease social isolation. Promotes the patients
comfort.
Discuss use of electronic voice box and esophageal speech prior Reduces anxiety and increases self-condence.
to discharge. Have the patient practice using device.
Encourage the patient to have recordings made for reaching Promotes safety, increases comfort, and decreases anxiety.
police, re department, doctor, or emergency medical service if
impaired verbal communication is a long-term condition.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor the patients potential for speech according to subjective Provides database needed to plan more complete and accurate
and objective components, to include: interventions.
Reported or documented previous speech capacity or
potential
Health history for evidence of cognitive, sensory, perceptual,
or neurologic dysfunction
Actual auditory documentation of speech potential
Assessment done by speech specialist
Patterns of speech of parents and signicant others
Cultural meaning attached to speech or silence of children
Any related trauma or pathophysiology
Parental perception of the childs status, especially in instances
of congenital anomaly such as cleft lip or palate
Identication of dominant language and secondary languages
heard or spoken in the family
Assist the patient and parents to understand needed explanations Provides teaching opportunity. Decreases anxiety, which can
for procedures, treatments, and equipment to be used in nursing interfere with communication.
care.
Encourage feelings to be expressed by taking time to understand Alternate methods of communication and sensitivity to attempts
possible attempts at speech. Use pictures if necessary for young at communication attach value to the patient and serve to
children. reinforce future attempts at communication.
Encourage family participation in care of the patient as situation Family input provides an opportunity for communication and
allows. fosters parent-child relationship.
Assist the family to identify community support groups. Provides long-term support for coping.
Assist the patient and family in determining the impact Family functioning relies heavily on communication.
Impaired Verbal Communication may have for family
functioning.
Provide information for long-term medical follow-up as Knowledge helps prepare the family for long-term needs and helps
indicated, especially for congenital anomalies. reduce anxiety about unknowns.
Assist in identication of appropriate nancial support if the Funding by third party payment may be available, depending on
child is able to qualify for help according to state and federal the patients medical status.
legislation.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
This nursing diagnosis will pertain to women the same as to any other adult. The reader is referred to the
other sectionsAdult Health, Psychiatric Health, and Home Health.
Psychiatric Health
NOTE: If impaired communication is related to alterations in physiology or surgical alterations, refer
to Adult Health nursing actions.
ACTIONS/INTERVENTIONS RATIONALES
Establish a calm, reassuring environment. Inappropriate levels of sensory stimuli can increase confusion and
disorganization.
If communication difculties are related to disorientation to
person, place, or time, provide appropriate environmental
cues to support orientation. These can include:
Calendars
Orientation boards
Seasonal decorations and conversations
Clocks with large numbers
Name signs on doors
Current event groups
Note those items that are necessary for this client with the
frequency of exposure needed to support the clients orientation.
If disorientation is related to delusions, refer to Disturbed
Thought Process (Chap. 7) for additional interventions.
Provide the client with a private environment if experiencing High levels of anxiety decrease the clients ability to process
high levels of anxiety, to assist him or her in focusing on information.
relevant stimuli.
Communicate with the client in clear, concise language. Inappropriate levels of sensory stimuli can increase confusion and
Speak slowly to the client. disorganization. When verbal and nonverbal behavior is not in
Do not shout. agreement, a double-bind or incongruent message may be sent.
Face the client when talking to him or her. These incongruent messages place the receiver in a darned if you
Role-model agreement between verbal and nonverbal do, darned if you dont situation and promote interpersonal
behavior. ineffectiveness.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for a 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 and implementing Family involvement enhances effectiveness of interventions.
strategies to decrease, prevent, or cope with Impaired Verbal
Communication:
Family conference: Discuss each members perspective of the
situation.
Teach the client and family appropriate information regarding Knowledge bases required to interact with the family member who
the care of a person with Impaired Verbal Communication: is verbally impaired.
Use of pencil and paper, alphabet letters, hand signals, sign
language, pictures, ash cards, or computer
Use of repetition
Assist the patient and family in lifestyle adjustments that may be Lifestyle changes require long-term behavioral changes. Support
required: enhances permanent changes in behavior.
Stress management
Changing role functions and relationships
Learning a foreign language
Acknowledging and coping with frustration with
communication efforts
Consult with or refer to appropriate assistive resources as Self-help groups and rehabilitation services can enhance the
required. treatment plans.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., uses esophageal Reassess using initial assessment factors.
speech; has had no problems with
air retention; has perceived no
difficulty in being understood.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target
date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Violence, Self-Directed and Other-Directed, giving away personal items, or taking out a large life insur-
ance policy
Risk for 19. Persons who engage in autoerotic sexual acts
DEFINITIONS8 B. Risk for Other-Directed Violence (Risk Factors)
1. History of violence
Risk For Self-Directed Violence Behaviors in which an individ- a. Against others: Hitting someone, kicking someone, spit-
ual demonstrates that he or she can be physically, emotionally, ting at someone, scratching someone, throwing objects
and/or sexually harmful to self. at someone, biting someone, attempted rape, rape, sex-
ual molestation, or urinating or defecating on a person
Risk For Other-Directed Violence Behaviors in which an indi- b. Threats: Verbal threats against property, verbal threats
vidual demonstrates that he or she can be physically, emotionally, against person, social threats, cursing, threatening notes
and/or sexually harmful to others. or letters, threatening gestures, or sexual threats
c. Anti-social behavior: Stealing, insistent borrowing, insis-
NANDA TAXONOMY: DOMAIN 11SAFETY/ tent demands for privileges, insistent interruption of
PROTECTION; CLASS 3VIOLENCE meetings, refusal to eat, refusal to take medication, or ig-
noring instructions
NIC: DOMAIN 4SAFETY; CLASS VRISK d. Indirect: Tearing off clothes, ripping objects off walls,
MANAGEMENT writing on wall, urinating on oor, defecating on oor,
stamping feet, temper tantrums, running in corridors,
NOC: DOMAIN IIIPSYCHOSOCIAL HEALTH;
yelling, throwing objects, breaking a window, slamming
CLASS OSELF-CONTROL
doors, or sexual advances
2. Neurologic impairment: Positive electroencephalogram
DEFINING CHARACTERISTICS8 (EEG), computed tomography (CT) scan, or magnetic res-
onance imaging (MRI); head trauma; positive neurologic
A. Risk for Self-Directed Violence (Risk Factors) ndings; or seizure disorders
1. Age 15 to 19 or older than 45 3. Cognitive impairment: Learning disabilities, attention decit
2. Marital status: Single, widowed, or divorced disorder, or decreased intellectual functioning
3. Employment: Unemployed; or recent job loss or failure 4. History of childhood abuse
4. Occupation: Executive, administrator, owner of business, 5. History of witnessing family violence
professional, or semiskilled worker 6. Cruelty to animals
5. Interpersonal relationships: Conictual 7. Firesetting
6. Family background: Chaotic or conictual, or history of 8. Prenatal and perinatal complications or abnormalities
suicide 9. History of drug or alcohol abuse
7. Sexual orientation: Active bisexual or inactive homosexual 10. Pathologic intoxication
8. Physical health: Hypochondriac, or chronic or terminal illness 11. Psychotic symptomatology: Auditory, visual, or command
9. Mental health: Severe depression, psychosis, severe person- hallucinations; paranoid delusions; or loose, rambling, or
ality disorder, or alcohol or drug abuse illogical thought processes
10. Emotional status: Hopelessness, despair, increased anxiety, 12. Motor vehicle offenses: Frequent trafc violations, or use of
panic, anger or hostility motor vehicle to release anger
11. History of multiple suicide attempts 13. Suicidal behavior
12. Suicidal ideation: Frequent, intense, or prolonged 14. Impulsivity
13. Suicidal plan: Clear and specic lethality; method and avail- 15. Availability and/or possession of weapon(s)
ability of destructive means 16. Body language: Rigid posture, clenching of sts and jaw, hy-
14. People who engage in autoerotic sexual acts peractivity, pacing, breathlessness, and threatening stances
15. Personal resources: Poor achievement, poor insight, or affect
unavailable and poorly controlled RELATED CLINICAL CONCERNS
16. Social resources: Poor rapport, socially isolated, or unre-
sponsive family 1. Physical abuse
17. Verbal clues: Talking about death, better off without me, 2. Organic brain syndrome; Alzheimers disease
or asking questions about lethal dosages of drugs 3. Attempted suicide
18. Behavioral clues: Writing forlorn love notes, directing angry 4. Epilepsy, temporal lobe
messages at a signicant other who has rejected the person, 5. Panic episode
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Refer to psychiatric nurse clinician (see Psychiatric Health Violence or risk for violence requires specic interventions by a
nursing actions). specialist in the area of mental health.
Monitor for signs of anger or distress such as restlessness, Monitors for deterioration of condition, and promotes early
pacing, wringing of hands, or verbally abusive behavior. intervention.
Accept anger of the patient, but do not participate in it when Anger is an acceptable behavior if appropriately handled, but
interacting with the patient. escalation of anger is to be avoided.
Remain calm. Set limits on the patients behavior, and reduce Decreases sensory stimuli. Decreases anxiety- and
environmental stimuli. violence-provoking situations.
Encourage the patient to verbalize angry feelings rather than Promotes an acceptable alternative strategy for dealing with anger.
physically demonstrating them or to physically demonstrate them
in constructive wayse.g., working out on a punching bag,
banging a trash can, or taking a walk. Schedule 30 min twice a
day at [times] to confer with the patient regarding this topic.
Let the patient know that he or she has control of own actions. Reinforces reality, and maintains limits on behavior.
He or she is responsible for own actions. Help the patient
identify situations that interfere with his or her control during
conferences with the patient.
Provide a safe environment by removing clutter, breakables, or Promotes safety, and reduces risk of harm to patients or others.
potential weapons. Restrain or seclude the patient as needed.
Observe, at least once an hour, for indications of suicidal Prevents self-inicted violence.
behavior, e.g., withdrawal, depression, or planning and
organizing for attempt.
Give medications as ordered (tranquilizer, sedative, etc.), and Determines effectiveness of medication as well as monitoring for
monitor effects of medication. unwanted side effects.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient and family to describe usual patterns of Insight into role-relationships is basic in determining the risk for
role-relationship activities. violence.
Monitor for precipitating or triggering events that seem to recur Risk indicators can be identied as assessment for repeated violence
as the pattern for violence is explored. is considered.
Assist the patient and family to describe their perception of the Insight of the patient or parents reveals basic data about the
actual or potential violence pattern. violence pattern, which assists in accurate intervention.
Provide opportunities for expression of emotions related to the Expression of thoughts and feelings in a directive age-appropriate
violence appropriate for age and developmental capacitye.g., manner helps the child understand the impact of the violence and
a toddler could use dolls, puppets, or other noninvasive methods. assists in reducing his or her anxiety.
Provide appropriate collaboration for long-term follow-up Valuing long-term follow-up fosters compliance and shows
regarding appropriate intervention. sensitivity to the patients needs for long-term support. Safety is
also at risk. In many instances, legal mandates dictate exact
protocols to be enforced.
Provide for role-taking by parents in a supportive manner when Supportive role-modeling provides a safe and nonjudgmental
possible. milieu for the parents to practice parenting and appropriate
behaviors with the child. It also allows for observation of
behaviors to follow reciprocity of parental-infant dyad or triad.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
NOTE: These actions relate specically to the abused, battered woman.5154
ACTIONS/INTERVENTIONS RATIONALES
All female clients should be screened for the presence of
violence upon entry into the health care system:
Have you ever been intentionally hurt by someone?
Are you afraid of your partner or signicant other?
Has your partner or signicant other ever made you feel
afraid, inadequate, or worthless?
Be alert for cues that might indicate battering, such as: Provides database necessary to accurately assess the true causative
Hesitancy in providing detailed information about injury and factor.
how it occurred
Explanation for injuries that are inconsistent with the injury,
e.g., trunk injury not consistent with a fall
Inappropriate affect for the situation
Delayed reporting of symptoms
Types and sites of injuries, such as bruises to head, throat,
chest, breast, or genitals
Inappropriate explanations
Increased anxiety in presence of the batterer
Injuries that are proximal, rather than distal, may indicate a
battering injury
Injuries that are in various stages of healing, e.g., old bruises
along with new bruises
Vague somatic symptoms with no visible cause
Provide a quiet, secure atmosphere to facilitate verbalization of Provides emotional support to the patient. Fosters security for the
fears, anger, rage, guilt, and shame. All discussions about patient so that she will realize that she is not alone or not the only
violence should be initiated and conducted with the patient person to have had this experience.
isolated away from the partner.
Provide information on options available to the patient, e.g., Provides basic information needed by the patient for future
womens shelters and legal aid societies. planning.
Assist the patient in raising her self-esteem by:
Asking permission to do nursing tasks
Involving the patient in decision making
Providing the patient with choices
Encouraging the patient to ask questions
Assuring the patient of condentiality
Listening to her concerns and choices without judging
Assist the patient in reviewing and understanding family
dynamics.
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Introduce self to the client, and call the client by name. Conditions that make people feel anonymous facilitate aggressive
behavior.55
If aggressive behavior is resulting from toxic substances, consult Staff and client safety is of primary concern.
with physician for medication and detoxication procedure.
Observe the client every 15 min during detoxication, assessing Client safety is of primary concern.
vital signs and mental status, until condition is stable.
Place the client in quiet environment for detoxication. Inappropriate levels of sensory stimuli can increase confusion and
disorganization.
Eliminate environmental stimuli that affect the client in a Inappropriate levels of sensory stimuli can increase confusion and
negative manner. This could include staff, family, and other disorganization, increasing the risk for violent behavior.
clients. Establish balance between being in control and being
controlling.
Provide a calm, reassuring environment. Respect the clients
requests for quiet, alone time.
Protect the client from harm by: Provides basic client safety.
Removing sharp objects from environment
Removing belts and strings from environment
Providing a one-to-one constant interaction if risk for
self-harm is high
Checking on the clients whereabouts every 15 min
Removing glass objects from environment
Removing locks from room and bathroom doors
Providing a shower curtain that will not support weight
Checking to see whether the client swallows medication
Observe the clients use of physical space, and do not invade Encroachment of the clients personal space may be perceived as
clients personal space. a threat.56
If it is necessary to have physical contact with the client, explain Claries role of staff to the client so that the intent of these
this need to the client in brief, simple terms before approaching. interactions is framed in a positive manner.
Remove unnecessary clutter and excess stimuli from the Inappropriate levels of sensory stimuli can increase the clients
environment. confusion and disorganization, thus increasing the risk for violent
behavior.
Talk with the client in calm, reassuring voice.
Do not make sudden moves.
Remove persons who irritate the client from the environment. The best intervention for violent behavior is prevention.
Observe the client carefully for signs of increasing anxiety and
tension.
Do not assume physical postures that are perceived as
threatening to the client.
If increase in tension is noted, talk with the client about Assists the client in developing coping behaviors.
feelings.
Help the client attach feelings to appropriate persons and Assists the client in developing coping behaviors that are
situationse.g., Your boss really made you angry this time. appropriate to the situation. Promotes the clients sense of control.56
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
If partner or family violence is an issue, arrange conjoint, Provides partners with an opportunity to develop alternative ways
solution-oriented treatment. This should include a of communicating and problem solving.60,61
no-violence contract between the partners.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
In cases of dementia, discuss with the caregiver if there is a Awareness of violence triggers provides guidelines to adjust
usual pattern of violence, e.g., does startling or speaking in environment and staff behaviors.
loud tones or having several people speaking at once usually
result in a violent outburst by the patient?
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention.
symptoms of the risk for violence:
Substance abuse
Increased stress
Social isolation
Hostility
Increased motor activity
Disorientation to person, place, and time
Disconnected thoughts
Clenched sts
Throwing objects
Verbalizations of threats to self or others
Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior require support.
required:
Recognition of feelings of anger or hostility
Developing coping strategies to express anger and hostility in
acceptable mannerexercise, sports, art, music, etc.
Prevention of harm to self and others
Treatment of substance abuse
Management of debilitating disease
Coping with loss
Stress management
Decreasing sensory stimulation
Provision of safe environment
Removal of weapons, toxic drugs, etc.
(continued)
Copyright 2002 F.A. Davis Company
Discuss workplace issues related to violence.64 Homicide is a leading cause of occupational death. Prevention is
needed.
Develop anticipatory guidance materials for violence Age-appropriate prevention strategies provide support for change.
prevention.64,65
Involve the patient and family in planning and implementing Provides for early intervention.
strategies to reduce the risk for violence:
Family conference
Mutual goal setting
Communication
Assist the client and family to set criteria to help them
determine when intervention of law enforcement ofcials or
health professionals is requirede.g., if the patient becomes
threat to self or others.
Consult with or refer to assistive resources as appropriate. Utilization of existing services is efcient use of resources.
Psychiatric nurse clinician and support groups can enhance the
treatment plan.
Copyright 2002 F.A. Davis Company
Risk for
Yes No
Record data, e.g., has chosen exercise Reassess using initial assessment factors.
and relaxation tape as alternative
methods; has successfully utilized both
according to self and family statements.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target
date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 10
Sexuality-Reproductive Pattern
611
Copyright 2002 F.A. Davis Company
reproductive structures. By the 12th week of fetal life, biologic sex Sadly, only 16 percent of the victims tell police about the attack,
is well established.1,2 with the victims being concerned about the family nding out, be-
Reactions by others begin the moment the biologic sex of the fe- ing blamed by others for the attack, and others knowing about the
tus or infant is known. Whether the sex of the infant is known be- attack. These concerns have decreased in victims raped in the past
fore birth or not until the time of birth, the parents and those about 5 years; however, in this group, there were increased concerns
them prepare for either a boy or a girl by buying clothes and toys about having their name become public, getting AIDS and other
for a boy (color blue, pants, shirts, football) or a girl (color pink, sexually transmitted diseases, and becoming pregnant. Conden-
frilly dresses, dolls), as well as speaking to the infant differently ac- tiality of name is a high priority for these victims.
cording to sex. Girls are usually spoken to in a high, singsong voice:
Oh, isnt she cute! whereas boys are spoken to in a low-pitched,
matter-of-fact voice: Look at that big boy. He will really make a Developmental Considerations
good football player one of these days! These actions contribute to INFANT
the infants gender identity and perception of self. Behavioral re-
sponses from the infant are elicited by the parents, based on their Erickson denes the major task of infancy as the development of
views of what roles a boy or girl should fulll. trust versus mistrust.4 The act of the parents nurturing and pro-
Gender role is determined by the kinds of sex behavior that are viding care-taking activities allows the infant to begin experiencing
performed by individuals to symbolize to themselves and others various pleasures and physical sensations, such as warmth, plea-
that they are masculine or feminine.3 Early civilizations assigned sure, security, and trust,1 and it is through these acts of nurturing
roles according to who performed what tasks for survival. Women that the infant begins to develop a sense of masculinity or feminin-
were relegated to specic roles because of the biologic nature of ity (gender identity). The infant is further molded by the parents
bearing and rearing children and gathering food. The men were the perceptions of sex-appropriate behavior through reward and pun-
hunters and soldiers. Advanced technologies, changing mores, ishment. Female infants tend to be less aggressive and develop
birth control, and alternative methods of securing food and rearing more sensitivity because girls are usually rewarded for being
children have led to changes in roles based on gender in Western good, and male infants develop more aggressively and learn to be
society. Gender roles are inuenced by cultural, religious, and so- independent because boys are told that big boys dont cry and
cial pressures. Gender role stereotypes are culturally assigned clus- they learn to comfort themselves. By the age of 13 months, sexual
ters of behaviors or attributes covering everything from play activ- behavior patterns and differences are in place,1,4 and core gender
ities and personal traits to physical appearance, dress and vocational identity is theorized to be formed by 18 months.7 These early be-
activities.4 haviors are so critical to ones core gender-identity that children
As in gender identity, researchers have noticed gender role-play who experience gender reassignment after the age of 2 years are
in children as young as 13 months. Schoolchildren are particularly high-risk candidates for psychotic disorders4 (p. 321).
exposed and pressured into gender role stereotyping by parents, The infant who is sexually abused is usually physically trauma-
teachers, and peers, who demand expected, rigid behavior patterns tized and many times dies. Developmental delays can be recognized
according to the sex of the child. Molding into gender roles is often in these children by failure to thrive, low weight or no weight gain,
accomplished by handling girls and boys differently. Little girls are lethargy, and at affect.
usually handled gently as infants, and adults fuss with their babys
hair and tell them how pretty they are; little boys are usually rough- TODDLER AND PRESCHOOLER
housed and are told What a big boy you are. Sex directional train-
ing is also accomplished by such verbalizations as Wheres Daddys Neuromuscular control allows toddlers to explore their environ-
girl? and Big boys dont cry; be a man.5 ment, interact with their peers,1,4 and develop autonomy and in-
North American society is moving toward a blending of male and dependence.7 Genital organs continue to increase in size but not in
female roles; however, stereotyping still exists. According to Schus- function. The toddlers vocabulary increases; he or she distin-
ter and Ashburn,4 stereotyping is not all bad, as it can help reduce guishes between male and female by recognizing clothing and body
anxiety arising from gender differences and may aid in the process parts; and he or she develops pride in his or her own body, espe-
of psychic separation from ones parents. Therefore, they conclude cially the genital area, as he or she becomes aware of elimination or
that stereotypes can provide structure and facilitate development as excretory functions. They need guidance and require parents to set
well as restrict development and become too rigid, thus interfering limits as they learn to hold on or let go in order to achieve a
with a childs potential. sense of autonomy.4 By the age of 3, they have perfected verbal
Ones sexuality is a continuing lifetime evolution, changing as terms for the sexes, understand the meaning of gender terms and
one matures and progresses through the life cycle. It is impossible the roles associated with those terms (e.g., girl is sister or mother,
to separate an individuals sexuality from his or her development, and boy is brother or father),1 and receive pleasure from kissing and
as sexuality combines the interaction of the biophysical and psy- hugging.7
chosocial elements of the individual. The preschooler is busy developing a sense of socialization and
According to a national research study6 Rape in America, rape purpose. Learning suitable behavior for girls and boys or sex role
occurs far more often than previously recognized. This study found behavior is the major task during the preschool years. Preschoolers
that 683,000 American women were raped in 1990, which is a far will often identify with the parent of the same sex while forming an
higher number than had been estimated. Almost 62 percent of attachment to the parent of the opposite sex. They are inquisitive
these women stated they were minors when they were raped, and about sex and are often occupied in exploration of their own bod-
about 29 percent stated they were younger than 11 when the rape ies and friends bodies. This will often be exhibited in group games
occurred. This indicates rape is most denitely a traumatic event such as doctor-nurse, urinating outside, or masturbating.7 The
for our young in America. Of the rapists, 75 percent were known toddlers concept of their bodies, not as a whole but as individual
by the victim, and included such persons as neighbors, friends, rel- parts, changes when as preschoolers they begin to develop an
atives, boyfriends, ex-boyfriends, husbands, or ex-husbands. Only awareness of themselves as individuals, and become more con-
22 percent of the rapists were strangers to the victim. In 28 percent cerned about body integrity and intactness.4
of the cases, injuries to the victim, beyond the rape itself, occurred. It is important to note that 6-year-olds are the age group most
Copyright 2002 F.A. Davis Company
32. Shock
33. Fear
APPLICABLE NURSING DIAGNOSES B. Rape-Trauma Syndrome: Compound Reaction
1. Change in lifestyle, for example, changes in residence, dealing
Rape-Trauma Syndrome: Compound with repetitive nightmares and phobias, seeking family sup-
Reaction and Silent Reaction port, or seeking social network support in long-term phase
2. Emotional reaction, for example, anger, embarrassment,
DEFINITIONS10 fear of physical violence and death, humiliation, revenge,
or self-blame in acute phase
Rape-Trauma Syndrome Sustained maladaptive response to a 3. Multiple physical symptoms, for example, gastrointestinal
forced, violent sexual penetration against the victims will and consent. irritability, genitourinary discomfort, muscle tension, or
Rape-Trauma Syndrome: Compound Reaction Forced, violent sleep pattern disturbance in acute phase
sexual penetration against the victims will and consent. The trauma 4. Reactivated symptoms of previous conditions, that is, phys-
syndrome that develops from this attack or attempted attack in- ical illness or psychiatric illness in acute phase
cludes an acute phase of disorganization of the victims lifestyle and 5. Reliance on alcohol and/or drugs (acute phase)
a long-term process of reorganization of lifestyle. C. Rape-Trauma Syndrome: Silent Reaction
1. Increased anxiety during interview, that is, blocking of as-
Rape-Trauma Syndrome: Silent Reaction Forced, violent sexual sociations, long periods of silence, minor stuttering, or
penetration against the victims will and consent. The trauma syn- physical distress
drome that develops from this attack or attempted attack includes 2. Sudden onset of phobic reactions
an acute phase of disorganization of the victims lifestyle and a long- 3. No verbalization of the occurrence of rape
term process of reorganization of lifestyle. 4. Abrupt changes in relationships with men
5. Increase in nightmares
NANDA TAXONOMY: DOMAIN 9COPING/STRESS 6. Pronounced changes in sexual behavior
TOLERANCE; CLASS 1POST-TRAUMA RESPONSES
RELATED FACTORS10
NIC: DOMAIN 4SAFETY; CLASS UCRISIS
MANAGEMENT A. Rape-Trauma Syndrome
1. Rape
NOC: DOMAIN VIFAMILY HEALTH; CLASS Z B. Rape-Trauma Syndrome: Compound Reaction
FAMILY MEMBER HEALTH STATUS To be developed.
C. Rape-Trauma Syndrome: Silent Reaction
DEFINING CHARACTERISTICS10 To be developed.
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Explore your own feelings about rape before initiating patient The nurses feelings can be sensed by the survivor and can
care. Maintain nonjudgmental attitude. Actively listen when the inuence the survivors coping and sense of self.
survivor wants to talk about the event. Encourage verbalization
of thoughts, feelings, and perceptions of the event. Explore basis
for and reality of thoughts, feelings, and perceptions.
Attend to physical and health priorities such as lacerations or Prompt attention to physical needs provides comfort and facilitates
infection with appropriate explanations and preparation. a trusting relationship.
Promote trusting, therapeutic relationship by spending at least Promotes expression of feelings and validates reality.
30 min every 4 h (while awake) at [times] with the survivor.
Use calm, consistent approach when interacting with the survivor. Assists in reducing anxiety.
Respect the survivors rights.
Be supportive of the survivors values and beliefs. The survivors sexuality is intimately linked to his or her
value-belief system.
Explain need for medicolegal procedures, procedures to assess Enlists the survivors cooperation, and prepares her for events in
for sexually transmitted diseases, prophylactic medications, and case charges are led against the alleged rapist.
medications to avoid postcoital contraception before performing
procedures. Refer to Womens Health nursing actions for
specics about procedures.
Provide for appropriate privacy and health teaching as care is Avoids perpetuating the survivors fear as a result of necessity of
administered. Allow the survivor to see own anatomy if this examination and treatment in the same body area involved in the
seems appropriate as part of health teaching. rape. Could promote a sensation of rape recurrence.
Assist the survivor in activities of daily living (ADLs) after Promotes a slight sense of return to normalcy. Emotional shock
examination. may render the survivor temporarily unable to perform basic
ADLs.
Determine to what degree or extent symptoms of physical Basic database needed to plan for long-term effects of rape.
reactions exist, such as:
Pain or body soreness
Disturbances in sleep
Altered eating patterns
Anger
Self-blame
Mood swings
Feelings of helplessness
Administer medications as ordered to alleviate pain, anxiety, or Allows time for the survivor to process event in a way that
inability to sleep, and teach the survivor how to safely take such maintains self-integrity and self-esteem.
medications.
When interacting with the survivor, recognize that she will
proceed at her own rate in resolving rape trauma. Do not rush
or force the survivor.
Identify available support systems, e.g., rape crisis center, and Support systems that know signs and symptoms of rape-trauma
involve the signicant other as appropriate. syndrome can provide help for both short-term and long-term
interventions. Promotes effective coping for the survivor.
Monitor coping in the survivor and signicant other until Monitors for adaptive and maladaptive coping strategies. Provides
discharged from hospital. opportunity to assist the survivor and signicant other to practice
alternative coping strategies.
Assist the survivor to identify own strengths in dealing with Helps build the survivors self-esteem and overcome self-blame.
the rape.
Provide anticipatory guidance about the long-term effects of Helps prepare for expected and unexpected reactions in self,
rape. Promote self-condence and self-esteem through positive friends, and signicant others.
feedback regarding strengths, plans, and reality.
Provide for appropriate epidemiologic follow-up in cases of Required by law.
venereal disease.
Collaborate with other health care professionals as needed. Promotes holistic approach and more complete plan of care.
Arrange for appropriate long-term follow-up before dismissal Provides for long-term support.
from hospital, e.g., counseling.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage collaboration among health professionals to best Specialist will be required to deal with the unique needs of the
address the patients needs. young child enduring rape. The likelihood exists for incest or a
closely related individuals being identied as the one who
committed the act.
Try to establish trust as dictated by age and circumstances
related to rape trauma (with nurse being same sex as the patient).
Do not leave the child alone. Be gentle and patient.
Infants and Toddlers: Ensure continuity of caregivers. Explain
procedures with dolls and puppets.
Preschoolers: Ensure continuity of caregivers. Allow the
singling out the child as not being the cause of this incident.
in resolving this crisis for any patients of this age group. Look
Follow up with appropriate documentation and coordination of Appropriate protocols for documentation and reporting of rape or
child protective service needs. Assist the parents or guardians in incest must be followed according to state and federal guidelines.
signing proper release forms. Determine whether situation
involves incest.
Assist the patient to deal with residual feelings such as guilt for Resolution of unresolved guilt or feelings about the event must be
revealing or identifying assailant (in young children this often dealt with as soon as the clients condition permits.
must be dealt with within the family or extended-family
situations) by allowing at least 30 min per shift (while awake)
at [times]. Use simple language when dealing with the child.
Encourage the family members to assist in care and follow-up Risk behaviors serve as cues to alert the family or caregiver to
of the patients reorganization plans: monitor the childs progress in resolving the crisis.
Be alert for signs of distress such as refusing to go to school,
dreams, nightmares, or verbalized concerns.
INCEST
Monitor for inappropriate sexual behavior among family Provides database needed to accurately assess for incest.
members.
Monitor for children who know more about the actual
mechanics of sexual intercourse than their developmental age
indicates they would.
Monitor for girls who seem to have taken over the mothers
role in the home.
Monitor for mothers who have withdrawn from the home, either
emotionally or physically.
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the survivor through the procedures for provision of Provides database necessary for intervention. Secures
necessary health care treatment. Explain each phase of chain-of-evidence procedure, and assists in reducing anxiety for
examination to the survivor. Remain with the survivor at all the client.
times.
Obtain history:
List of previous venereal diseases
List of previous pelvic infections
Any injuries that were present before attack
Obstetric and menstrual history
Assist in gathering information to provide proper health and
legal care.
Secure the survivors description of any objects used in the
attack and how these objects were used in the attack.
Maintain sequencing and collection of evidence (chain of
evidence):
Label each specimen with:
(1) Survivors name and hospital number
(2) Date and time of collection
(3) Area from which specimen was collected
(4) Collectors name
(1) Clothing and items that are wet, e.g., with blood or Plastic bags will cause molding of wet items.
evidence:
(2) Pluck (do not cut) 23 pubic hairs from the patient, and
authorities.
(1) Injuries
(2) Sexually transmitted disease: AIDS, gonorrhea, or syphilis
(3) Pregnancy
Report to proper authorities any suspicion of family violence. Initiates long-range support for the patient.
Evaluate for increased rate of changing residences, repeated Provides database that allows accurate interpretation of long-range
nightmares, and sleep pattern disturbance. impact. Provides information needed to plan long-term care.
Encourage the patient to discuss phobias, frustrations, and fears.
Be available and allow the patient to express difculties in Provides long-term essential support.
establishing normal ADLs and redescribe attack as needed.
Assist the patient in developing a plan of reorganization of ADLs. Promotes realistic planning for problem while avoiding continued
denial of problem.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Assign a primary care nurse to the client. This nurse should be Promotes the development of a trusting relationship.
of the sex the client demonstrates most comfort with at the
current time.
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
In the event of the rape being secondary to elder abuse, refer Provides a resource for the older adult to explore options and
the patient to adult protective services. prevent recurrence of problem.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
During the acute phase, be sure that appropriate assessment, Early and accurate intervention decreases sequelae and provides
law enforcement involvement, and treatment of physical injuries documentation for any legal action.
or sexually transmitted diseases are provided.
Assist the client and family in lifestyle changes that may be Provides support and enhances recovery.
needed:
Treatment for physical injuries or sexually transmitted
disease
Testimony in court
Protection
Coping with terror, nightmares, or fear
Coping with alterations in sexual response to signicant
others
Stress management
Assist the client and family in planning and implementing Crimes of violence upset the family equilibrium and require
strategies for resolution of Rape-Trauma Syndrome: support to correct.
Communication, e.g., discussion of feelings among family
members
Mutual sharing and trust Involvement of the client and signicant others is important to
Problem solving, e.g., providing support for the family ensure successful resolution.
members and client; strategies to reduce possibility of future
attacks
Consult with or refer the patient to assistive resources as Use of existing resources and expertise provides high-quality care
appropriate. and is effective use of already available resources.
Copyright 2002 F.A. Davis Company
Interview the patient. Explore feelings, perceptions, and so on. Did the
patient make X number of positive statements?
Yes No
Record data, e.g., states, feeling much Reassess using initial assessment factors.
better; no longer think I asked for it;
made 5 positive statements.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target date,
and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Facilitate communication between the patient and partner by Promotes identication of issues involved in sexual dysfunction.
providing at least [number] minutes per day for privacy to
communicate.
Encourage the patient and partner to talk about concerns and Sexual behavior includes verbal, nonverbal, genital, and nongenital
problems during conference. activities.
Talk with the patient and partner about alternative ways to
attain sexual satisfaction and express sexuality, e.g., hugging,
touching, kissing, masturbation, hand holding, or sexual aids.
Provide factual informational material.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
This diagnosis is not appropriate for a child.
Womens Health
NOTE: Very little information is found in the literature on Sexual Dysfunction of lesbian women, as
they often conceal their sexual orientation when they receive health care and some choose not to receive
health care if there is a danger of exposure.14 The following actions refer to those who have a hetero-
sexual relationship.
ACTIONS/INTERVENTIONS RATIONALES
Obtain detailed sexual history. Provides database needed to plan accurate intervention.
Determine who the patient is:
Female
Male
Couple or partners
Review communication skills between partners
Ascertain the couples knowledge of:
Sexual performance
Female and male anatomy and physiology
Female and male orgasm
Anticipatory performance anxiety
Unrealistic romantic ideas
Rigid religious conformity
Negative conditioning in formative years
Erection and ejaculation
Stimulation
Arousal
Sexual anxiety
Fear of failure
(continued)
Copyright 2002 F.A. Davis Company
Fear of rejection
Dispel sexual myths and fallacies or misinformation about Provides basic information and support that can assist the patient
sexuality by: in long-term care.
Allowing the patient to talk about beliefs and practices in a
nonthreatening atmosphere
Obtain description of current problem: Provides essential database to permit narrowing of focus for
Psychological intervention.
Physical
Social
Determine type of sexual dysfunction:
General
Lack of erotic feeling
Lack of sexual responses
No pleasure in sexual act
Consider it an ordeal
Avoidance
Frustration
Disappointment
Fear
Disgust
Orgasmic difculties
If the client is sexually responsive but cannot complete sexual
response cycle, determine whether this is:
Situational: Client is inhibited, disappointed, or disinterested.
Physiologic: Interruption results from lack of lubrication,
impotence, or interference with sexual response cycle.
Psychiatric Health
NOTE: If sexual dysfunction is related to physiologic limitations, loss of body part, or impotence, re-
fer to Adult Health care plan. If dysfunction is related to ineffective coping or poor social skills, initi-
ate the following actions.
ACTIONS/INTERVENTIONS RATIONALES
Set limits on the inappropriate expression of sexual needs. Note Promotes the clients sense of control, while maintaining the safety
the kinds of behavior to be limited and the consequences for of the milieu.
inappropriate behavior heree.g., when the client approaches
staff member with sexually provocative remarks, the staff
member will use constructive confrontation and discontinue the
interaction.15 Inform the client of these limits.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for use of medications that may induce sexual dysfunction. Identies correctable source of impotency.
Male impotency may be related to antihypertensive medications.
Determine the individual patients knowledge of facts and myths Knowledge of expected aging changes may encourage the individual
regarding sexual changes in aging. to discuss changes experienced and seek treatment for dysfunction.
Identify resources for assistance with sexual dysfunction, such Provides an information source and support for individuals with a
as Impotents Anonymous groups.20 common problem. Impotence, regardless of etiology, shows marked
increase beyond age 65.
Provide resources for patients with chronic illnesses, such as
chronic obstructive pulmonary disease (COPD) or arthritis, that
address and assist in problem solving regarding disease-related
sexual difculties.21
Provide uninterrupted time for couples, particularly in Assists patients in maintaining sexuality as long as possible.
long-term-care settings, where it may be difcult to maintain or
attain privacy.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and signicant other in planning and Sexual dysfunction affects and is affected by relationships.
implementing strategies for reducing sexual dysfunction and Involvement of signicant people in strategies is vital to
enhancing sexual relationship: enhance the potential for success.
Communication, e.g., discussion of concerns and ideas for
intervention
(continued)
Copyright 2002 F.A. Davis Company
Sexual Dysfunction
Yes No
Record data, e.g., compares current Reassess using initial assessment factors.
sexual functioning favorably with
previous sexual functioning; states,
stress management techniques helped
both of us. Record RESOLVED. Delete
nursing diagnosis, expected outcome,
target date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Establish therapeutic and trusting relationship with the patient Promotes therapeutic and open communication.
and signicant other.
Address other primary nursing needs, especially physiologically Meeting these needs promotes solving of the ineffective sexuality
related and self-image related. pattern.
Actively listen to the patients and signicant others efforts Promotes open and therapeutic communications.
to talk about fears or changes in body image affecting
sexuality or altered sexual preferences. Assist the patient and
family to identify how the desired sexual function may be
attained.
Help the patient and signicant other to understand that Misinformation and myths may create unrealistic expectations
sexuality does not necessarily mean intercourse. about sexuality and the sexual experience.
Discuss alternative methods for expressing sexuality, including Sexuality includes verbal, nonverbal, genital, and nongenital sexual
masturbation. activities.
(continued)
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the child and family to verbalize perception of altered Provides the database necessary to accurately plan intervention.
sexual functioning, e.g., undescended testicle.
Assist the patient and family to identify how the desired sexual Specic plans for goals of sexual function desired will assist in how
function may be attained. the client will be treated, e.g., surgeries for future procreation.
Include appropriate collaboration with other health care team Specialist may best meet the unique needs represented with
members as needed. ineffective sexual functioning.
Provide attention to developmentally appropriate role modeling Opportunities appropriate for age with role models serve as
for age and situation. valuable learning modes.
Encourage peer support during hospitalization as appropriate. Peer support fosters sense of self, which is also a composite of
sexuality.
Plan for potential long-term nursing follow-up. The chronic nature of many physiologic components will
necessitate serial rechecks and treatment over time as the child
grows and matures.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to describe her sexuality and understanding of Provides database needed to plan for successful interventions.
sexual functioning as it relates to her lifestyle and lifestyle
decisions.
Allow the patient time to discuss sexuality and sex-related
problems in a nonthreatening atmosphere. Obtain a complete
sexual history, including current emotional state.
Assist the patient in listing lifestyle adjustments that need to be
madee.g., different methods of achieving sexual satisfaction
in the presence of mutilating surgery.
Identify signicant others in the patients life and involve them,
if so desired by the patient, in discussion and problem-solving
activities regarding sexual adjustments.
Provide atmosphere that allows the patient to discuss freely: Assists the patient in planning coping strategies to various life
Partner choice situations, and provides information the patient needs to achieve
Sexual orientation the planning.
Sexual roles
Assist the patient in identifying lifestyle adjustments to each
different cycle of reproductive life:
Puberty
Pregnancy
Menopause
Postmenopause
Discuss pregnancy and the changes that will occur during Provides essential information needed by the patient to offset
pregnancy and the postpartum period: concerns regarding maintaining sexuality during and after
Sexuality pregnancy.
Mood swings
Discuss aspects of sexuality and intercourse during pregnancy.
Answer questions promptly and factually:
(continued)
Copyright 2002 F.A. Davis Company
Frequency
Effects on fetus
Effects on pregnancy
intercourse:
(1) Cuddling
(2) Massaging, stroking, or touching partner
(3) Masturbation
Psychiatric Health
NOTE: If alteration is related to altered body function or structure or illness, refer to Adult Health
nursing actions.
ACTIONS/INTERVENTIONS RATIONALES
Assign primary care nurse who is comfortable discussing Promotes the development of a trusting relationship.
related material with the client.
Primary nurse will spend [number] minutes [number] times a
day with the client discussing issues related to diagnosis. These
discussions will include:
Clients use of prescription and nonprescription medications. Prescription and nonprescription medications can have a negative
If current medications could have a negative impact on sexual impact on sexual functioning.
functioning, assist the client in discussing possible medication
changes with primary health care provider.
Clients current physiologic health Disease states can have a negative impact on sexual functioning.
This can include cardiovascular disease and diabetes.
Clients thoughts and feelings about alteration Expression of feelings and perceptions in a supportive environment
Other stressors and concerns in the clients life that could facilitates the development of alternative coping behaviors.
affect sexual patterns
Clients perceptions of partners responses
Clients perceptions of self as a sexual person without a
partner
Clients perceptions of social or cultural expectations
Clients thoughts and feelings about sexuality
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the older adult with this diagnosis are the same as for the Adult Health patient.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to Ineffective Sexuality Patterns Provides database for early identication and intervention.
by [date].
Involve appropriate family memberse.g., signicant others or Sexual behavior can affect the entire family. Involvement of the
parents of childin planning, implementing, and promoting family in problem identication and intervention enhances the
reduction or elimination of Ineffective Sexuality Patterns: probability of successful intervention.
Communicatione.g., discussion of values and sexual mores
Mutual sharing and trust
Problem solvinge.g., identication of strategies acceptable
to all involved with the role of each person identied
Assist the client and family with lifestyle adjustments that may Provides knowledge and support necessary for permanent
be required: behavioral change.
Providing accurate and appropriate information regarding
sexuality and contraception
Providing time and privacy for development and
transsexuality
Consult with assistive resources as indicated. Specialized counseling may be indicated. Use of existing resources
provides effective use of resources.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has identified fatigue Reassess using initial assessment factors.
and stress as major factors; has attended
stress management conference; states,
Attention to time management has
helped. Record RESOLVED. Delete
nursing diagnosis, expected outcome,
target date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 11
CopingStress Tolerance
Pattern
Stress has been dened as the response of the body or the system a. Yes (Defensive Coping)
response history of the individual, family, or community.2 Coping a. Yes (Ineffective Denial)
challenge when a routine or automatic response is not readily 6. Does the patient downplay condition?
available.3 Thus, the coping pattern is the systems pattern of re- a. Yes (Ineffective Denial)
stress is affected by a complex interaction of physical, social, 7. Does the patient verbalize nonacceptance of health status
gaining an understanding of the interaction of these factors within a. Yes (Impaired Adjustment)
633
Copyright 2002 F.A. Davis Company
11. Does the client state concerns about care being received from systems experience as a part of living. This stress calls on the
primary caregiver? self-regulating processes of the system for adaptation. Intrasystem
a. Yes (Compromised Family Coping) coping mechanisms are used, and the system does not require as-
b. No sistance from outside sources to adapt. Level 2 responds to less-
12. Can the primary caregiver verbalize understanding of care re- routine or new experiences encountered by the system. The system
quirements? experiences a mild alarm reaction that is not prolonged. The indi-
a. Yes vidual system might experience a mild increase in heart rate, sen-
b. No (Compromised Family Coping) sations of bladder fullness and increased frequency of urination,
13. Does the family indicate physical and emotional support for temporary insomnia, tachypnea, anxiety, fear, guilt, shame, or frus-
the client? tration. Some outside assistance may be necessary to facilitate adap-
a. Yes (Readiness for Enhanced Family Coping) tation. This assistance could be in the form of identifying stressors
b. No and strengths or encouraging the individual to solve problems.
14. Does the family or primary caregiver indicate interest in a sup- Level 3 consists of the moderate amount of stress that occurs when
port group? a persistent stress is encountered or when a new situation is per-
a. Yes (Readiness for Enhanced Family Coping) ceived as threatening. Emergency adaptation processes are acti-
b. No vated. The individual would experience tachycardia, palpitations,
15. Does the patient exhibit re-experience of traumatic events tremors, weakness, cool pale skin, headache, oliguria, vomiting,
(ashbacks or nightmares)? constipation, and increased susceptibility to infections. This level
a. Yes (Post-Trauma Syndrome) of stress usually requires assistance from a professional helper. This
b. No assistance can include identifying problems and coping strengths,
16. Does the patient exhibit vagueness about traumatic event? teaching, performing tasks for the client, or altering the environ-
a. Yes (Post-Trauma Syndrome) ment to facilitate coping. When the system cannot adapt to a stress-
b. No ful situation with assistance, a severe degree of stress is experienced.
17. Is there evidence of positive communication and community This is labeled level 4. This occurs when all coping strategies are ex-
participation in planning for predicted community stressors? hausted. Intervention at this level requires the assistance of profes-
a. Yes (Readiness for Enhanced Community Coping) sionals who have the skills to assist with the development of unique
b. No coping strategies.
18. Is there evidence of community conict and decits in com- Because stress is life itself, adaptation to reduce the effects of
munity participation? stress on the system is imperative. To begin this process, it is im-
a. Yes (Ineffective Community Coping) portant to understand those factors that can inuence the systems
b. No ability to respond to stress. Stress can arise from biophysical, chem-
19. Has the patient threatened to kill himself or herself? ical, psychosocial, and cultural sources. The basic health of the af-
a. Yes (Risk for Suicide) fected system improves the ability to respond to these stressors. Re-
b. No sponse to the biophysical-chemical stressors can be improved by
20. Has the patient demonstrated marked changes in behavior, at- improving the condition of the biologic system. This would include
titude, or school performance? proper nutrition, appropriate amounts of rest, appropriate levels of
a. Yes (Risk for Suicide) exercise, and reduced exposure of the system to toxic chemicals.1
b. No The literature1 indicates that a great deal of psychosocial-cultural
stress evolves from a philosophy of life that is impossible to fulll.
This would indicate that a great deal of stress arises from the per-
Conceptual Information ception of events, not in the events themselves. This is com-
To understand coping, one must rst understand the concept of pounded by the social and cultural inuences on the system. The
stress, because coping is the systems attempt to adapt to stress. An sociocultural inuences could include the cultural attitudes about
understanding of these concepts and their relationship is crucial for age, body appearance, and family roles and the social approaches
the promotion of well-being. Research has clearly demonstrated to assistance for working mothers, advancement in employment
that undue stress can be related to major health problems if inap- status, and so on. The systems beliefs about these social-cultural
propriate coping is present.1 stressors can affect the degree to which the stressors affect the
Stress has been dened as the bodys nonspecic response to any system. If the stressor is perceived as unnatural or impossible to
demand placed on it.1 These demands can be any situation that would adapt to, the systems stress level will be increased. Response to the
require the system to adapt. For the individual, this could include any- psychosocial-cultural stressors can be improved with attitude as-
thing from getting out of bed in the morning to experiencing the loss sessment and interventions that reduce the physiologic response to
resulting from a major environmental disaster. Stress is life. psychosocial stressors.
The bodys physiologic response to stress involves activation of Coping has been dened as behavior (conscious and unconscious)
the autonomic nervous system. The symptoms of this activation can that a system uses to change a situation for the better or to manage
include sweating, tachycardia, tachypnea, nausea, and tremors. This the stress-resultant emotions.5 These kinds of behavior can occur on
process has been labeled the general-adaptation syndrome (GAS)4 and the biologic, psychological, and social levels. Effective coping uses
occurs in three stages: alarm reaction, resistance, and exhaustion. biologic, psychological, and social resources in attempts to manage
The alarm stage mobilizes the systems defense forces by initiating the situation.
the autonomic nervous system response. The system is prepared for A coping model has been presented3 that addresses the biologic,
ght or ight. In the resistance stage, the system ghts back and psychological, and sociocultural aspects of this process. The model
adapts, and normal functioning returns. If the stress continues and indicates that systems have generalized resistance resources (GRRs) to
all attempts of the system to adapt fail, exhaustion occurs, and the facilitate coping. GRRs are those characteristics of the system that
system is at risk for experiencing major disorganization. can facilitate effective tension management. Genetic characteristics
Four levels of psychophysiologic stress responses have been de- that provide increased resistance to the effects of stressors are con-
scribed.4 The rst level comprises the day-to-day stressors that all sidered physical and biochemical GRRs. These GRRs can include
Copyright 2002 F.A. Davis Company
situations can include role changes, peer difculties, threats to body with life experience can facilitate creative problem solving with the
integrity, rapidly changing body functioning, conict with parents, support of health care personnel.11
personal failures, sexual awareness, and school demands.10
Response to traumatic events is similar to that of adults. Etiolo- FAMILY LIFE CYCLE
gies of crisis-producing events, for this age group, are also similar
to those for adults. Specic events that place this age group at The following is a presentation of the developmental framework of
greater risk are those that affect the peer group and could have ef- the family life cycle as described by Carter and McGoldrick.12
fects on body image or sexual functioning. Coping behavior is
adultlike. This age group may nd support from peers especially Between Families The unattached young adult: The process of
useful in facilitating coping. Coping may also be affected by limited this level is accepting parent-child separation. The individ-
life experience and impulsive behavior. ual must separate from his or her family of origin and de-
Illnesses that threaten body image could result in difculties in velop intimate peer relationships and a career.
adjustment. Peers again provide a primary support system and can Joining of Families Through Marriage The newly married
have a great impact on the adolescents acceptance. Educating sig- couple: The process of this level involves commitment to a
nicant peers about the clients situation could facilitate their ac- new system. The individuals form a marital system and re-
ceptance of the client and in turn facilitate the clients adjustment align relationships with extended families and friends to in-
to the change in health status. Adjustment could also be facilitated clude spouse.
by involving the client in a support group composed of peers with Family with Young Children The task faced is to accept a new
similar alterations. generation of members into the system. The marital system
adjusts to make space for the child(ren) and assumes parent
roles. Another realignment takes place to include parenting
YOUNG ADULT and grandparenting roles.
Symptoms of problems with coping include changes in perfor- Family with Adolescents The family task is to increase exi-
mance of roles at home and at work, aggressive behavior directed bility of family boundaries to include childrens indepen-
at self or others, and physical symptoms associated with anxiety dence. The parent-child relationships shift to allow the ado-
and denial. Changes in role performance might include loss of in- lescents to move in and out of the system. The parents
terest in sexual relationships or withdrawal from the community. refocus on midlife marital and career issues, and there is a
Situations that might tax the coping abilities of the young adult in- beginning shift toward concerns for the older generation.
clude balancing increasing role responsibilities, dealing with Family in Later Life Accepting the shifting of generational
threats to the self or to body integrity, leaving home, and making roles is the task of this stage. The system maintains individ-
career choices.10 ual and couple functioning and interests in conjunction with
Alterations in health status that affect the ability of role perfor- physiologic decline. There is an exploration of new role op-
mance place this age group at risk for impaired adjustment. This tions with more support for a more central role for the mid-
could include loss of ability to function in job responsibilities. Be- dle generation. The system also makes room for the wisdom
havior can include regression, but this does not necessarily indicate and experience of the elderly and to support the older gen-
that the client is experiencing impaired adjustment. eration without overprotecting them. This stage will also in-
clude coping with the deaths of signicant others and prepa-
ration for death.
ADULT
Specic problems can arise in family coping when the family de-
Coping resources have broadened for this age group as a result of velopmental cycle or expectations do not correspond with the de-
past successful coping experiences and the possible addition of adult velopmental tasks of individual family members. There are three
children as supports during crisis. Symptoms of difculties with stages that are nodal points in family development.
coping are similar to those of the young adult. Age-related stressors The joining of families through marriage requires a commitment
include loss, such as signicant others and physical functioning; role to a new system. If the separation from the parents is not success-
changes, such as job loss and the leaving of adult children; aging par- ful, then the new family does not have an opportunity to form its
ents; career pressures; and cultural role expectations.10 own identity, combining the experiences both bring into this new
relationship. Symptoms of unsuccessful resolution of this stage
OLDER ADULT could result in the marital partners returning home to their parents
when conict arises or an ongoing struggle over loyalties to fami-
Symptoms of extreme stress in this age group may be overlooked lies of origin.
and attributed to senility. These symptoms include withdrawal, de- The second major shift occurs when children enter the system.
creased functioning, increased physical complaints, and aggressive The new role of parent is assumed, and the couple boundaries must
behavior. Decreased function of hearing, vision, and mobility as be opened to accept the child. Unsuccessful resolution of this stage
well as loss of support systems and other resources affects coping could result in physical or emotional abuse of the child. If there is
behavior. These problems can be balanced by life experience that a developmental delay in the parents and they are not ready to as-
has provided the individual with many situations of successful cop- sume the responsibilities that accompany parenthood, family dys-
ing to fall back on during stressful times. Situations that place this function can occur.
age group at risk are multiple losses, decreased physical function- A family with adolescents is faced with the task of increasing ex-
ing, increased dependence, retirement, relocation, and loss of re- ibility to include childrens independence. This may require a ma-
spect because of cultural attitudes. jor shift in family rules. This is also inuenced by the parents per-
The effects of multiple losses related to alteration in health status ception of the adolescent and the environment. If the adolescent is
and the loss of support systems place the older adult at risk for im- seen as being competent, and the environment that the adolescent
paired adjustment. In the absence of illness affecting cognitive func- interacts in is seen as safe, then it will be much easier for the fam-
tioning, the older adult can assume responsibility for making deci- ily to provide the necessary shifts in relationships. When this stage
sions related to alterations in health status. This ability combined is not resolved successfully, the adolescent may enhance behavior
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Establish a therapeutic relationship with the patient and A therapeutic relationship promotes cooperation in the plan of care
signicant others by showing empathy and concern for the and gives the patient a person to talk with.
patient, calling the patient by name, answering questions
honestly, involving the patient in decision making, etc.
Explain the disease process and prognosis to the patient. Knowledge of disease process and limitations is necessary for
adjustment.
Encourage the patient to ask questions about health status by Increasing knowledge and understanding leads to improved
allowing opportunity and asking the patient to share his or her coping and adjustment.
understanding of the situation.
Encourage the patient to express feelings about disease process Verbalization of feelings leads to understanding and adjustment.
and prognosis by sitting with the patient for 30 min once a shift
at [times]. Use techniques such as active listening, reection,
and asking open-ended questions.
Identify previous coping mechanisms, and assist the patient to Determines what coping strategies have been successful, and
nd new ones. provides an opportunity to try new strategies.
Help the patient nd alternatives or modication in previous Helps the patient continue to have satisfaction in activities, and
lifestyle behavior by using assistive devices, changing level of provides a sense of control in lifestyle.
participation in activities, learning new behaviors, etc.
Encourage independence in self-care activities by focusing on Provides a sense of control, and increases self-esteem and
the patients strengths, rewarding small successes, etc. adjustment.
Refer to psychiatric nurse practitioner (see Psychiatric Health Collaboration promotes holistic approach to care, and problems
nursing actions). may need intervention by specialist.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for all possible etiologic factors via active listening by Provides the database needed to most accurately plan care.
asking questions that are appropriate for the child (who, what,
where, and when) regarding rst feeling of not being able to
adjust.
Help the child realize it is normal to need some time and Realistic planning increases the likelihood of compliance and
assistance in adjusting to changes, e.g., the child needing increases sense of success.
assistance with ambulating following surgery.
Explore the childs and familys previous coping strategies. Previous coping strategies serve as critical information in
developing interventions for the current status.
Identify ways the child can feel better about coping with the Effective coping can empower the child and family and thereby
needed adjustment, including reinforcement of desired afford a positive adjustment.
behavior.
Assist the child and family in creating realistic goals for Realistic goals enhance success.
coping.
Collaborate with related health team members as needed. Collaborations with specialists serve to meet the unique needs of
the patient and family.
Provide clear and simple explanations for procedures. Simple and clear instructions promote the childs functioning while
in a stressful situation.
Address educational needs related to health care. Knowledge serves to empower and provide guidelines for
compliance with expected behavior.
Deal with other primary care needs promptly. Basic primary needs require prompt attention to offer the best
likelihood of minimizing adjustment difculty.
Provide for posthospitalization follow-up with home care as Follow-up affords long-term resolution of adjustment.
needed.
Assist the patient and family in identication of community Identication of resources before discharge will encourage the
resources that can offer support. patient and family to use the resources as needed and will help
them cope with the changes in their lifestyle.
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
COUVADE SYNDROME
When counseling with expectant fathers, be alert for Provides database that allows early intervention.
characteristics for couvade syndrome.16
Syndrome affects males only.
Wives are pregnant and usually in the third or ninth month
of gestation.
Symptoms are conned to the gastrointestinal (GI) or
genitourinary (GU) system; notable exceptions are toothache
and skin growths.
Anxiety and affective disturbances are commone.g.
constant worrying about labor events, I cant do this or
I just know I will faintand/or overmanaging arrangements
for he new babye.g., painting nursery three times.
Physical ndings are minimal.
Laboratory and x-ray testing yields normal results.
Patient makes no connection between his symptoms and his
wifes pregnancy.
Provide a nonjudgmental atmosphere to allow the patient (in Encourages the patient to talk about feelings, and allows planning
this instance, a man with the medical diagnosis of couvade of how to channel feelings into activities that will assist in
syndrome) to express concerns of: preparing for fatherhood.
Self-image as a father
Relationship with his father
Self-responsibility
Feelings about wifes or partners pregnancy
Concerns about wifes or partners safety
Accurately record physical symptoms described by the Allows more effective interventions and planning.
expectant father:
Fatigue
Weight gain
Nausea or vomiting
Headaches
Backaches
Food cravings
Support and guide the expectant father through the changes
being experienced.
Assure the expectant couple that: Emphasizes that this is not necessarily unusual behavior. Assists
Expectant fathers can suffer physical symptoms during with positive actions that support both partners, and allows the
partners pregnancy. man to view pregnancy realistically.
Pregnancy affects both partners.
Fathers also have emotional needs during pregnancy.
POSTPARTUM AFFECTIVE DISORDERS
Postpartum Blues
This affects approximately 50 to 85 percent of all delivering
women, is viewed as part of the adaptation process to
childbirth, and usually resolves with normal support of family;
therefore, it is not considered to be an impairment and will not
be discussed here.
Postpartum Depression
Described as postpartum major affective disorder in psychiatric
literature (usually occurs 2 wk to 3 mo post partum).
Encourage the client to express fears about the less-than-perfect
infant. This can include:
Low-birth-weight infant
Different sex than desired by parents
Fussy infant
Premature infant
(continued)
Copyright 2002 F.A. Davis Company
Continually assess the new mothers mood, observing for Nursing observations can be critical in getting these patients the
signs of: professional help they need. Too often women feel this is just part
Continuous crying of being a new mother and that they have no one who will listen.
Insomnia not related to care of the infant Often these signs and symptoms go unreported and unrecognized
Mood swings by family members.17
Loss of appetite
Withdrawal
Irritability
Guilt feelings
Feeling of inability to care for self or the infant or function in
roles of wife and mother
Impaired memory
Lowered self-image
Provide nonjudgmental atmosphere for the patient to discuss Encourages the patient to discuss feelings and verbalize
problematic situations. Issues may include: disappointments or problems so that plans for coping with reality
Partners lack of sexual interest of birth experience can be initiated.
Any illness or problems with older children
Marital status
Disappointment in experience (unwanted cesarean section,
medications administered during labor, or any unexpected
occurrences)
so on)
Postpartum Psychosis
The incidence of postpartum psychosis is approximately 1 in
1000 deliveries. Onset is acute and abrupt.17
Obtain a complete patient history and family history, particularly
regarding previous depressive or psychotic episodes. (Usually
has familial and/or genetic basis.)
Collaborate with family members to never leave the patient
alone, particularly with the infant.
Arrange for the family to take and care for the infant.
If needed, arrange for community resources for care of the infant.
Obtain immediate assistance from psychiatric health colleagues This diagnosis needs professional assistance immediately and is
for the mother. beyond the scope of practice for perinatal nursing. The main duty
of the perinatal nurse is to see that no harm comes to the mother
or infant until mental health colleagues can assume care of the
mother.
Explain to family the likelihood of repetition of psychosis with
subsequent pregnancies.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the client his or her perception of the current Communicates respect for the client and his or her experience of
alteration in health status. This should include information the stressor, which promotes the development of a trusting
about the coping strategies that have been attempted and his or relationship. Provides information about the clients strengths that
her assessment of what has made them ineffective in promoting can be utilized to promote coping, and provides the nurse with an
adaptation. opportunity to support these strengths in a manner that promotes
a positive orientation.
Provide the client with clocks and calendars to promote Maintains the clients cognitive strengths in a manner that will
orientation and involvement in the environment. facilitate the development of coping strategies.6
Give the client information about the care that is to be provided, Promotes the clients sense of control.
including times for treatments, medicines, group, and other
therapy.
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health
and mental health patient.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for factors contributing to impaired adjustmente.g., Provides database for intervention.
psychological, social, economic, spiritual, or environmental
factors.
Involve the client and family in planning, implementing, and Family involvement enhances effectiveness of interventions.
promoting reduction or elimination of impaired adjustment:
Family conference: Discuss feelings and altered roles, and
identify coping strategies that have worked in the past.
Mutual goal sharing: Establish realistic goals and specify role
support self-care.
a hearing aid.
Assist the client and family in lifestyle adjustments that may be Family relationships can be altered by impaired adjustment.
required: Permanent changes in behavior and family roles require evaluation
Stress management and support.
Development and use of support networks
Treatment for disability
Appropriate balance of dependence and independence
Grief counseling
Change in role functions
Treatment for cognitive impairment
Provision of comfortable and safe environment
Activities to increase self-esteem
Consult with or refer to appropriate assistive resources as Utilization of existing services is efcient use of resources.
indicated. Resources such as an occupational therapist, a psychiatric nurse
clinician, and support groups can enhance the treatment plan.
Copyright 2002 F.A. Davis Company
Adjustment, Impaired
FLOWCHART EVALUATION: EXPECTED OUTCOME
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
Nursing actions specic for this diagnoses will require implementation in the home and community
environment; therefore, the reader is referred to the Home Health nursing actions for this diagnosis.
Child Health
Same as for Adult Health, with acknowledgement of parents and caregivers assuming role of advocacy.
Use developmentally appropriate approach. May be dependent on funding or interest of local potential
supporters.
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
lochia)
Psychiatric Health
Refer to Home Health actions and interventions for these care plans.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
(continued)
Copyright 2002 F.A. Davis Company
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve community groups in problem identication and Involvement at the local level enhances community development
program development: and communication.
Identify local needs for addressing problems or stressors.
Encourage participation in the community process.
Identify community strengths and weaknesses. Community recognition of strengths, weaknesses, and resources
Develop strategies to enhance strengths and correct enhances the potential.
weaknesses.
Develop collaborative relationships within the community to Supportive relationships enhance the success of the plan.
promote development of the community.
Utilize strategies identied for enhanced community coping to
identify factors leading to Ineffective Community Coping:
Develop strategies to correct the decits.
Develop plan with community involvement to correct decits.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., exhibits only 2 of Reassess using initial assessment factors.
the defining characteristics. List here.
Record RESOLVED. (May want to use
CONTINUE until no characteristics
present.) Delete nursing diagnosis,
expected outcome, target date, and
nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage and assist the family and signicant others to Allows for identication of specic stressors, and promotes
verbalize their needs, fears, feelings, and concerns by sitting creative problem solving.
with the patient for 30 min per shift at [times] or planning a
family conference. Actively listen and facilitate discussion.
Provide accurate information about the situation. Claries misconceptions and misunderstanding.
Include the family and signicant others in decision making Promotes active participation, motivation, and compliance.
and plan of care when planning care and intervening.
Assist the family and signicant others to identify and explore Promotes creative problem solving.
alternatives to dealing with the situation, e.g., respite care,
Moms day out, or daycare centers.
Assist the family and signicant others to identify before Community resources can help strengthen family coping process
discharge sources of community support that could assist and prevent isolation of the family.
them to cope with their feelings and to supply relief when
needed.
Encourage the family to provide time for themselves on a Reduces stresses and strengthens coping skills.
regular basis.
Initiate referral to psychiatric clinical nurse specialist as needed. Problems may need intervention by specialist.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage the child and family to express feelings and fears by Expression of concerns provides insight into views about problem
allotting 30 min per shift, while awake, for this purpose. and the values of the patient and family.
Review family dynamics previous to crisis. Family dynamics in usual times is paramount in understanding
coping dynamics during times of stress.
Encourage family members to participate in the childs care, Family and patient input ensures individualized plan of care.
including bathing, feeding, comfort, and diversional activity. Provides teaching opportunity, and increases the childs security.
Provide education to all family members regarding the childs Reduces anxiety, increases likelihood of compliance, and
illness, prognosis, and special needs as appropriate. empowers the family.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
NOTE: This diagnosis would be most likely to relate to the single mother in the area of Womens
Health.
ACTIONS/INTERVENTIONS RATIONALES
Review the physical, mental, social, and economic status of the Provides a database that can be used to plan appropriate
single mother, taking into account if she is widowed, divorced, interventions and locate support systems for the patient.
single and a parent by choice, or single and a parent not by
choice. (See Impaired Adjustment.)
Identify support system available to the single mother e.g.,
family, friends, coworkers, or formal support groups such as
church or community organizations.
Review the patients perception of employment status, e.g., Assists the patient to realistically plan for scal needs of herself
educational level and skills, job opportunities, and opportunity and her infant. Allows identication of resources that could assist
for improvement of employment status. in improving income status.
Identify child care requirements considering the age of children,
who has legal custody of children, and child support (nancial
and emotional).
Suggest strategies for exposing the children to male role Provides for male role modeling in the absence of a father gure.
models22:
Assign to classes with male teachers.
Ask for assistance from brothers or grandparents.
Involve the children in sports (coaches are usually male).
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Role-model effective communication by: Models for the family effective communication that can enhance
Seeking clarication 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
Each meeting with the family, provide positive verbal Promotes hope, and helps the family develop a positive view of
reinforcement related to the observed strengths. themselves and their abilities, promoting an environment for
change. Supports the development of a positive therapeutic
relationship.23
Demonstrate an understanding of the complexity of system Promotes the development of a trusting relationship, while
problems by: developing a positive orientation.
Not taking sides in family disagreements
Providing alternative explanations of behavior patterns that
recognize the contributions of all persons involved in the
problem, including health care providers if appropriate
Requesting the perspective of multiple family members on a
problem or stressor
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
system and how they could best achieve the goals they have
Provide constructive confrontation to the family about Facilitates the development of functional coping behaviors in a
problematic coping behavior.24 Those kinds of behavior warm, supportive environment.
identied by the treatment team as problematic should be
listed here.
Teach the family methods to reduce anxiety, and practice and High levels of anxiety can interfere with adaptive coping behaviors.
discuss the use of these methods with the family [number] times Repeated practice of a behavior internalizes and personalizes the
per week. This should be done at least once a week until family behavior.
members are using this as a coping method. This could include
deep muscle relaxation, physical exercise, family games that
require physical activity, or cycling. Those methods selected by
the family should be listed here, with the time schedule for
implementation. The family should be given homework related
to the practice of these techniques at home on a daily basis.
Provide the family with the information about proper nutrition Proper nutrition promotes physical well-being, which facilitates
that was indicated as missing on the assessment. This should adaptive coping. Successful accomplishment of goals provides
include time spent on discussing how proper nutrition can t positive reinforcement and motivates behavior, while enhancing
the family lifestyle. This teaching plan should be listed here. A self-esteem.
homework assignment related to the necessary pattern change
should be given. This should involve all the family members.
Make an assignment that has high potential for successful
completion by the family.
If a homework assignment is not completed, do not chastise the Promotes positive orientation.
family. Indicate that the nurse misjudged the complexity of the
task, and assess what made it difcult for the family to complete
the task. Develop a new, less complex task based on this
information. If a family continues not to complete tasks, they
may need to be referred to an advanced practitioner for
continued care.
Monitor the familys desire for spiritual counseling, and refer to
appropriate resources. The name of the resource person should
be listed here.
Assist the family in identifying support systems and in
developing a plan for their use. This plan should be recorded
here.
Refer the family to community resources as necessary for Provides resources that can provide support in the community.
continued support.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Refer to adult protective services if risk of physical harm is high. Provides means for monitoring the patient and family. Effective use
of resources to reduce risk of harm for the patient.
Home Health
See Psychiatric Health nursing actions for detailed family-oriented interventions.
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement and clarication of roles are necessary to
strategies to improve family coping: enhance interventions.
Crisis management: Identify actions to identify crisis and
intervenee.g., removing individuals from situation.
(continued)
Copyright 2002 F.A. Davis Company
Yes No
Has family identified effect these No Reassess using initial assessment factors.
strategies have on family?
Yes
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Provide opportunities for the family and signicant others to Promotes understanding, open communication, creative problem
discuss the patients condition and treatment modalities by solving, and growth.
scheduling at least one family session every other day.
Include the family and signicant others in planning and Promotes active participation, motivation, and compliance.
providing care as care is planned and implemented. Provides a teaching opportunity and an opportunity for the family
to practice in a supportive environment.
Provide instruction as needed in supportive and assistive Understanding and knowledge base are needed to adapt to
behavior for the patient. situations. Reduces anxiety.
Answer questions clearly and honestly. Promotes a trusting relationship.
Refer the family and signicant others to support groups and Coordination and collaboration organize resources and decrease
resources as indicated. duplication of services. Provides a broader range of networked
resources.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Identify how the child views the current crisis by using play, The impact of the crisis on the child is basic data needed for
puppetry, etc. planning care.
(continued)
Copyright 2002 F.A. Davis Company
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage participation of signicant others in preparation for Enhances support system for the patient, and promotes positive
birth, e.g., spouse, boyfriend, partner, children, in-laws, anticipation of birth.
grandparents, and others who are important to the individual.
Discuss childbirth and the changes that will occur in the family
unit.
Encourage the patient to list family lifestyle adjustments that Provides directions for anticipation of birth, and allows more
need to be made. Involve signicant others in discussion and long-range planning that can prevent crises.
problem-solving activities regarding family adjustments to the
newborn, e.g., child care, working, household responsibilities,
social network, or support groups.
Encourage the woman and partner (signicant other) to attend Provides basic information that assists in easing labor experience.
childbirth education classes or parenting classes in preparation Promotes a more positive birth experience, and reduces anxiety.
for the birthing experience.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Talk with the family to identify their goals and concerns. Promotes development of a trusting relationship by communicating
respect and concern for the family.
Assist the family in identifying strengths. Promotes a positive orientation.
Commend family strengths at each meeting with the family. Promotes hope, and helps the family develop a positive view of
themselves and their abilities, promoting an environment for
change. Supports the development of a positive therapeutic
relationship.23
Refer the family to appropriate community support groups. Provides support networks in the community.
Teach the family those skills necessary to provide care to an ill Provides the family with an increased repertoire of behavior that
member. they can use to effectively cope with the situation.
Talk with the family about the role exibility necessary to cope Assists the family in anticipatory planning for the necessary
with an ill member and how this may be affecting their family. adjustments that could evolve from the present situation.
Anticipatory planning increases their opportunities for successful
coping, which enhances self-esteem.
Provide the family with information about normal developmental Promotes sense of control, and increases opportunities for
stages and anticipatory guidance related to these stages. successful coping.
Discuss with the family normal adaptive responses to an ill Promotes the familys strengths.
family member, and relate this to their current functioning.
Support appropriate family boundaries by providing information Promotes healthy family functioning.
to the appropriate family subgroup.
Model effective communication skills for the family by using Effective communication improves problem-solving abilities.
active listening skills, I messages, problem-solving skills, and
open communication without secrets.
Spend 1 h with the family on a weekly basis providing them Behavioral rehearsal provides opportunities for feedback and
with the opportunity to practice communication skills and to modeling of new behaviors by the nurse.
share feelings (if this is an identied goal).
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health
and mental health patient.
Home Health
See Psychiatric Health nursing actions for specic family-oriented activities.
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement in planning enhances growth and
strategies to enhance health and growth: implementation of the plan.
Family conference: Identify family strengths.
Mutual goal setting: Establish family goals, and identify
specic activities for each family member.
Assist the family and client in lifestyle adjustments that may be Support enhances permanent behavioral changes.
required:
Provide information related to health promotion.
Provide information related to expected growth and
development milestones, both individual and family.
Consult with and refer to assistive resources as appropriate. Community services provide a wealth of resources to enhance
growthe.g., service organizations such as Lions Club, Altrusa,
etc., colleges and universities, or recreational facilities.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., interviews elicited positive Reassess using initial assessment factors.
statements regarding progress; family as a
whole communicating more and doing
more together. Record RESOLVED. Delete
nursing diagnosis, expected outcome, target
date, and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to identify and explore specic situations that Identication of problem area is the rst step in problem solving
are creating stress and possible alternatives for dealing with the and promotes creative problem solving.
situation by allowing at least 1 h per shift for interviewing and
teaching.
Help the patient evaluate which methods he or she has used Allows for strengthening of effective coping methods and
that have not been successful or have been only partially elimination of ineffective ones.
successful.
Monitor for and reinforce behavior suggesting effective coping Strengthens and enhances coping skills. Increases condence to
continuously. risk new coping strategies.
Maintain consistency in approach and teaching whenever Reduces stress. Promotes trusting relationship.
interacting with the patient.
Encourage participation in care by assisting the patient to Promotes self-care, enhances coping, builds self-esteem, and
maintain activities of daily living to degree possible. increases motivation and compliance.
Encourage support from the family and signicant others by Broadens support network. Builds self-esteem in support systems.
allowing participation in care, encouraging questions, and
allowing expression of feelings.
Teach relaxation techniques such as meditation, exercise, yoga, Reduces stress, and provides alternative coping strategies.
deep breathing, or imagery. Have the patient practice for 10 min
twice a shift at [times].
Assist the patient to identify and use available support systems Broadens support network to reach short-term and long-term
before discharge from hospital. goals.
Initiate referral to psychiatric clinical nurse specialist as needed. Specialized skills may be needed to intervene in signicant
problem areas.
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Establish a trusting relationship with the child and respective Promotes communication, and allows gathering of data that
family by allowing time (30 min) per shift, while awake, for enhance care planning.
verbalization of concerns and their perception of the
situation.
Identify need for collaboration with related health team members. Specialist, e.g., mental health, may best be able to deal with the
problem.
Reinforce appropriate behavior of choosing or coping by verbal Positive reinforcement will enhance learning of coping
praise. mechanisms.
Assist the patient and family in setting realistic goals. Realistic goals enhance success, which increases coping ability.
Provide appropriate attention to primary nursing needs. Meeting of primary care needs allows the patient to focus energy
on coping.
Offer education to provide clarication of information as needed, Provides basic knowledge needed to avoid future crises. Increases
regarding any health-related needs. options for coping choices.
Determine appropriate developmental baseline behavior versus Baseline data will provide valuable information for comparative
actual coping behavior. follow-up.
Administer medications as ordered, including sedatives. Relaxation assists in decreasing anxiety. Conserves energy to deal
with crisis.
Set aside time each shift [specify] to deal with how the child and Acting out or expression of feelings provides valuable data that
parents feel about the defensive behavior. This may require art, increase the likelihood of a successful plan of care.
puppetry, or related expressive dynamics.
Provide feedback with support for progress. When progress is Feedback serves to clarify and allows for reviewing the specic
not occurring, provide reective referral back to the child and coping activity with reteaching as needed.
parent as applicable.
Provide ongoing information regarding the childs health status, Factors related to coping may well be inuenced by residual effects
which could affect defensive behavior by the child or parents. from illness. Misinformation or lack of information can also be
detrimental to positive coping.
Throughout defensive coping period, monitor and ensure the Basic standard of care.
childs safety.
Determine disciplinary plans for all to abide by with safety in Structured limit setting will provide security and safety.
mind.
Provide appropriate reality confrontation according to readiness Reality confrontation helps keep perspective on here and now and
of the child and parents. is a useful approach to initiate coping with current situation.
Provide for discharge planning with reinforcement of value of Attaching value to follow-up increases the likelihood of
follow-up appointments as needed. satisfactory attendance for appointments and other follow-up
activities.
Identify, along with the patient and family, resources to assist in Support groups provide empowerment and a sense of shared
coping, including support groups. concern.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Identify groups at risk for ineffective individual coping, Provides database that allows for early recognition, planning, and
e.g., single parent, minority women, women with superwoman action.
syndrome, and lesbians.
Identify situations that place patients at risk for ineffective
individual copinge.g., unwanted or unplanned pregnancy,
unhappy home situation (marriage), demands at work, or
demands of children or spouse. (See Impaired Adjustment for
Postpartum Depression.)
Assist the patient in identifying typical stressful timese.g.,
at home, at work, in social situations, or during an average
day.
Assist the patient in identifying lifestyle adjustments that may Supports the patient in identication and planning of strategies to
be made to lower stress levelse.g., planning for divorce or reduce stress.
planning for job change (either part-time or unemployment for
a period of time).
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Determine the clients functional abilities and developmental Cognitive abilities can impact the clients ability to develop
level for the adaptation of all future interventions. The results appropriate coping behaviors.
of this assessment should be noted here.
Discuss with the client his or her perception of the current Promotes the development of a trusting relationship by
crisis and stressors. This should include information about the communicating respect for the client.
coping strategies that the client has attempted and his or her
assessment of what has made them ineffective in resolving this
stressor or crisis.
Assist the client in developing an appropriate time frame for the De-catastrophizes the clients perceptions of the situation.27
resolution of the situation. (Often when experiencing a crisis,
the individual has the perception that resolution must take
place immediately.) This could include, as appropriate to the
clients situation:
Informing the client that any difculty that has taxed his or
her resources as much as this one has will take an extended
time to resolve because it must be complex
Informing the client that a situation that is as important as
this one is to the individuals future deserves a well-thought-
out answer and that a decision should not be made hastily
Assisting the client in determining the source of the time
pressure and the appropriateness of this time frame
Assisting the client in developing an appropriate perspective
on the time frame (One question that could be useful is
What would be the worst that could happen if this problem
is not resolved by [put clients stated time frame here]?)
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Discuss with the patient any recent life changes that may have Recent or multiple losses may signicantly impact usual coping
affected his or her coping, such as loss of a loved one, relocation, skills.
loss of best friend, or loss of a pet.30
Home Health
See Psychiatric Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions.
strategies to improve individual coping:
Family conference: Identication of problem and role each
family member plays.
positive manner.
support
Identify signs and symptoms of illness. Permanent changes in behavior and family roles require support
and accurate information.
Point out hazards and benets of home remedies, self-diagnosis,
and self-prescribing.
Consult with and refer the patient to assistive resources as Utilization of existing services is efcient use of resources.
appropriate. Resources such as a psychiatric nurse clinician, a family therapist,
and support groups can enhance the treatment plan.
Copyright 2002 F.A. Davis Company
Yes No
No Finished
Copyright 2002 F.A. Davis Company
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Establish a therapeutic relationship by actively listening, calling Promotes trust and open expression of feelings.
the person by name, showing empathy and concern, not
belittling feelings, etc.
Avoid prolonged waiting periods for the patient for routine This tactic may have been one used by the torturer, and standard
procedures. care procedures, e.g., drawing blood or electrocardiography, may
be perceived as torture because of the memories they evoke.31
Encourage the patient to express feelings about the event by Provides database for planning interventions.
actively listening, asking open-ended questions, reection, etc.
Help the patient see the event realistically by clarifying Provides objective view. Promotes problem solving.
misconceptions and looking at both sides of the situation.
Before discharge, help the patient identify support groups who Enhances coping methods. Promotes use of community resource
have previously experienced the same or similar traumatic events. networks to help meet short- and long-term goals and advocate
for the patient.
Initiate a psychiatric nursing consultation as needed. Situation may require specialized skills to intervene.
Help the patient identify diversional activities to activate when Provides alternative coping strategy.
he or she feels he or she is going to re-experience the event.
Orient the patient to reality as needed. Helps the patient focus on here and now rather than on past
events.
Engage the patient in social interactions with nurses or with Decreases isolation. Encourages communication. Provides
other support groups as appropriate. diversional activity.
Teach the patient relaxation and stress management techniques Reduces stress. Promotes alternative coping methods.
before discharge.
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Monitor for details surrounding the incident causing Circumstances surrounding the event may provide clues as to
Post-Trauma Syndrome. how the child may be internalizing people, places, and objects as
symbols or reminders.
Allow for developmental needs in encouraging the child to Appropriate methods should help resolve the emotions
express feelings about trauma: surrounding the incident and avoid further traumatization.
Play for infants
Puppets or dolls for toddlers
Stories or play for preschoolers
Deal appropriately with other primary nursing needs, e.g., Allows focusing of energy on dealing with the crisis.
nutrition or rest.
Provide for one-to-one care and continuity of staff. Enhances trust.
Encourage the patient and family to note positive outcomes of Potential for growth exists in crisis management.
experience, e.g., being able to deal with crisis.
Review previous coping skills. Coping may be enhanced by consideration of previous skills
within framework of current situation.
Address educational needs according to situation, e.g., rights of Knowledge provides empowerment and enhances decision
the individual or related follow-up. making.
Allow for visitation by the family and signicant others. Family visitation offers opportunity for reassurance and promotes
resuming daily routines and relationships.
Refer the patient appropriately for continuity and follow-up after Continuity and follow-up will foster likelihood of resolution of
discharge from hospital. major conicts.
Provide for diversional activity of the childs choice. Promotes relaxation.
Allow for potential sleep disturbances. Provide favorite toy or Recurrent nightmares may occur as a result of the trauma.
security object. Offer adequate comforting such as by holding
the infant on waking.
Provide for follow-up for delayed Post-Trauma Syndrome up to Delayed response can be noted long after the initial event and
2 yr after the trauma. must be included in the planning of care.32
Reassure the child that he or she is not being punished and is Depending on the cognitive level and coping ability, the child
not responsible for trauma. may associate the event as being caused by something wrong he
or she did or said.
Womens Health
This nursing diagnosis will pertain to the woman the same as to any other adult. The reader is referred to
Rape-Trauma Syndrome (Chap. 10) and to the other nursing actions in this section.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Assign a primary care nurse to the client, and assign the same Promotes the development of a trusting relationship.
staff member to the client each day on each shift.
Begin appropriate anxiety-reducing interventions if this is a Provides the client with increased repertoire of coping behaviors
signicant problem for the client. (See Anxiety, Chap. 8, for to cope with intense emotional experiences.
detailed intervention strategies and assessment criteria.)
Discuss with the client his or her perception of the current Promotes the clients sense of control, while communicating
situation and stressors. This should include information about respect for the clients experience.
the coping strategies that the client has attempted and his or
her assessment of what has made them ineffective in resolving
this situation.
If the client describes or demonstrates high levels of guilt, assess Clients with guilt related to the experience may view suicide as a
for suicide risk and implement appropriate precautions. Note way to end this guilt.33
here the actions to be taken. (See Chap. 9, Risk for Violence,
Self-Directed, for detailed interventions.)
Provide a quiet, nonstimulating environment or an environment Inappropriate levels of sensory stimuli can increase confusion and
that does not add additional stress to an already overwhelmed disorganization.
coping ability. (Potential environmental stressors for this client
should be listed here, with the plan for reducing them in this
environment.)
(continued)
Copyright 2002 F.A. Davis Company
(continued)
Copyright 2002 F.A. Davis Company
Gerontic Health
The nursing actions for a gerontic patient with this diagnosis are the same as those given for the adult
health and mental health patient.
Home Health
See Psychiatric Health nursing actions for detailed interventions. If family violence is involved, refer to
Chapter 9.
ACTIONS/INTERVENTIONS RATIONALES
Ask the client to describe the precipitating event. Assists the nurse in understanding the clients perception of the
crisis and its impact.
Determine the clients perception of the stress.
Assess sources of support, resources, and usual coping methods.
Identify which coping strategies that the client has previously Crisis can produce growth if effective skills are applied in future
used have been effective and which have not. Discuss ways that situations.
effective strategies can be used to cope with future crises.29
Assist the client in implementing adaptive coping mechanisms.
Reinforce and encourage the use of healthy coping responses. Assists the nurse in mobilizing resources and reinforcing adaptive
actions.
Copyright 2002 F.A. Davis Company
Interview the patient and significant others. Has the patient returned to
pretrauma behavior?
Yes No
Record data, e.g., reports self-destructive Reassess using initial assessment factors.
thoughts are no longer a problem; impulse
control has improved; irritability has
decreased; infrequently discusses event.
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target date,
and nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
b. Terminal illness
Suicide, Risk for c. Chronic pain
DEFINITION15 7. Social factors
a. Loss of important relationships
At risk for self-inicted, life-threatening injury. b. Disrupted family life
c. Grief or bereavement
NANDA TAXONOMY: DOMAIN 11SAFETY/ d. Poor support systems
PROTECTION; CLASS 3VIOLENCE e. Loneliness
f. Hopelessness
NIC: DOMAIN 4SAFETY; CLASS UCRISIS g. Helplessness
MANAGEMENT h. Social isolation
i. Legal or disciplinary problem
NOC: DOMAIN IIIPSYCHOSOCIAL HEALTH; j. Cluster suicides
CLASS OSELF-CONTROL
RELATED FACTORS15
DEFINING CHARACTERISTICS15
The risk factors also serve as the related factors.
1. Behavioral factors
a. History of prior suicide attempt
b. Impulsiveness RELATED CLINICAL CONCERNS
c. Buying a gun
1. Any chronic disorder, for example, rheumatoid arthritis, multi-
d. Stockpiling medicines
ple sclerosis, or chronic pain
e. Making or changing a will
2. Psychiatric illness or disorder
f. Giving away possessions
3. Chemical use or abuse
g. Sudden emphatic recovery from a major depression
4. Recent, multiple losses
h. Marked changes in behavior, attitude, or school performance
2. Verbal factors
a. Threats of killing oneself
b. States a desire to die or end it all HAVE YOU SELECTED
3. Situational factors THE CORRECT DIAGNOSIS?
a. Living alone
b. Retired Risk for Self-Mutilation This diagnosis refers
c. Relocation or institutionalization to the patient causing self-injury; however,
d. Economic instability there is no intent to kill oneself.
e. Loss of autonomy or independence
Risk for Violence, Self-Directed This
f. Presence of gun in home
diagnosis can be labeled as a combination of
g. Adolescents living in nontraditional settings: juvenile deten-
Risk for Self-Mutilation and Risk for Suicide.
tion center, prison, halfway house, or group home
Using this diagnosis rather than Risk for
4. Psychological factors
Suicide would not be a problem because the
a. Family history of suicides
interventions for both diagnoses are
b. Alcohol and substance use or abuse
essentially the same.
c. Psychiatric illness or disorder, for example, depression, schiz-
ophrenia, and bipolar disorder
d. Abuse in childhood
e. Guilt EXPECTED OUTCOME
f. Gay or lesbian youth
5. Demographic factors Will demonstrate a [percent] decrease in risk factors by [date].
a. Age: elderly, young adult males, or adolescents
b. Race: Caucasian or Native American TARGET DATES
c. Gender: male
d. Divorced or widowed Because of the life-threatening consequences of this diagnosis,
6. Physical factors progress should be monitored on a daily basis.
a. Physical illness
Adult Health
The Psychiatric Health nursing actions also serve as the Adult Health nursing actions.
Copyright 2002 F.A. Davis Company
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Assess for all contributing factors, including the childs or A holistic and complete assessment will provide the most thorough
parental subjective data, objective data, primary and secondary database for individualized care.
references.
Identify any threats or expression of related high-risk factors Verbalization of ideation must be taken seriously.
suggesting low self-esteem or lack of self-worth.
Identify history of any past suicide ideation. Tendency for recurrence is often noted with one suicide ideation
providing risk index.
Identify ways to enhance communication for the child and Communication will provide cues to how the client is feeling, with
family to best express feelings on an ongoing basis. an avenue for dialogue.
Explore value conicts and meaning these have for the client Freedom to explore thoughts about values will assist in noting
and family. uniqueness of each individual, while attempting to also respect the
familys views.
Identify ways to assist the child and family to identify cues Knowledge is enhanced with recognition of patterns per individual
suggestive of suicidal risk. and family.
Provide appropriate attention to role of medications if these are Knowledge about drugs will assist in safe, effective compliance
ordered, with focus on desired effect, appropriate dosing and with regimen.
timing, importance of parents securing supply in a safe place,
expected side effects, possible toxicity, and ways to reduce
toxicity vs. importance of maintenance of blood levels.
Ensure environmental safety as noted per adult plus frequent Client safety is paramount.
surveillance every 10 min or constant as may be required.
Identify appropriate peer support group activities, and The sense of isolation is reduced with peers who may be able to
encourage group activities. relate to similar feelings.
Collaborate with other members of health team, such as child Expertise will best provide for needs of the child and family.
life specialist, child psychologist or psychiatrist.
Utilize developmentally appropriate strategies to encourage Expression of feelings may be facilitated through means other than
ongoing expression of feelings and/or ways to cope with suicidal verbalization and must be considered paramount in the child with
tendency. suicidal risk.
Identify with the child and family a plan to deal with the risk Input from the child and family will best reect and demonstrate
for suicide. the need for anticipatory planning in event of possible recurrence.
Identify a plan for gradual resumption of daily activities, such Prior planning lessens anxiety and affords time to resume
as school and extracurricular activities, well before actual activities per individual coping strategies.
dismissal.
Identify a plan for follow-up in advance of dismissal. Appropriate follow-up planning lessens likelihood of crisis or
recurrence before situational or precipitating factors can be
controlled.
Womens Health
The nursing interventions for a woman with this diagnosis are the same as those actions in Psychiatric
Health.
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Introduce self and call the client by name. Conditions that encourage feelings of anonymity facilitate
aggressive behavior.34
Frame suicide as one option or solution to the problem. Promotes a problem-solving approach without prompting a power
struggle between the staff and the client around this option.
Inform the client about the limits of condentiality. Plans to Honesty promotes the development of a trusting relationship.
harm himself or herself or someone else must be shared with
the treatment team and necessary authorities.
Protect the client from harm by: Provides an environment that promotes client safety.
Asking the client what in the environment could pose harm
for them.
Removing sharp objects from environment.
Removing belts and strings from environment.
(continued)
Copyright 2002 F.A. Davis Company
self-harm is high.
one-to-one observation.
Sit with the client [number] minutes [number] times each day.
(Note person responsible for this here.) Use this time to:
Have the client tell his or her perspective of the situation, Facilitates the development of a trusting environment for open
including feelings. expression of concerns.23 Communicates to the client that his or
her welfare is important to the staff.35
Commend the clients strengths. Increases the clients awareness of strengths, which promotes a
context of change and alternative problem solutions, while
providing hope.23,36
Explore the clients past attempts to cope with concerns. Facilitates understanding of the clients perception of the problem.
Change is dependent on problem perception.23
If suicidal behavior is inuenced by intoxication, consult with Intoxication with drugs and alcohol can have a negative impact on
primary care provider for detoxication procedure. the clients ability to make decisions.35
If suicidal behavior is inuenced by command hallucinations, Command hallucinations place clients at high risk for self-harm.35
provide one-to-one observation until the client no longer
describes these thoughts. Refer to Disturbed Thought Process
(Chap. 7) for detailed interventions for hallucinations.
Contract with the client to talk with staff member when he or Promotes the clients sense of control by assuring the client that if
she feels or thinks the risk for suicide is high. he or she needs help controlling his or her behavior, the staff has
a specic plan to help. Assures the client of staff availability.35,37
When the client is capable of group interactions, assign him or Facilitates the clients development of social skills and social
her to a support group. Note schedule for group interactions contacts.36
here.
Schedule regular times with primary nurse for the client to
explore: (Note times and person responsible for these
interactions here.)
Need to carry out this problem solution at this time. Removing the immediacy of this solution set can provide the client
with time to develop alternative solutions.
Exploring past solutions. Assists in facilitating understanding of the clients perception of the
problem.
Exploring solution sets that enlist creative problem solving. Facilitates the clients learning new problem-solving strategies.
These might include what the client would tell a friend to do, Promotes the clients sense of control.
three wishes, generating a long list of solutions that are not
assessed for their practicality in the initial problem-solving
stages.
When solutions are generated, note the support the client needs
Develop with the client a system to reward the use of new Positive reinforcement encourages behavior.
problem-solving strategies. Note the behavior that is to be
rewarded and the reward system here.
Attend recreational activities with the client. Choose activities Provides the client with alternative outlets for anger or
that have a high potential for client success. Note activities here aggression, while promoting a sense of belonging and self-worth.38
and person responsible for attending with the client.
Develop with the client a list of support groups in the Social isolation increases the risk for suicide.36,38
community that will be utilized after discharge. Note the
support groups here with names of contact persons.
Arrange meeting with the clients support system to provide Promotes connection with support system, and facilitates problem
information about alternative coping strategies and develop solving.36
positive communication patterns. Note times and frequency of
these meetings here.
Copyright 2002 F.A. Davis Company
Gerontic Health
NOTE: In the United States, the highest suicide rate is seen in the older, white male population. Older
adults rarely threaten to commit suicide. Usually they successfully take action rather than discuss the
possibility. With the graying of America comes a need for health care professionals to increase their
own and public awareness of this problem. The Psychiatric Health section for this diagnosis provides
information on nursing actions that can be used in conjunction with the following interventions.
ACTIONS/INTERVENTIONS RATIONALES
Obtain information regarding risk factors associated with suicide A combination of these risk factors is frequently present in older
in the elderly, such as loss of spouse in the past year, history of adults who commit suicide.
depression, social isolation, physical decline, loss of
independence, and terminal diagnosis.39
Refer to social support services for assistance in meeting Introduces means of dealing with changing life circumstances.
changing care needs.40
Refer for hospice support if the older adult has been diagnosed Provides interdisciplinary resources and support for the older
with a terminal illness and meets hospice admission criteria.40,41 client.
Question older adults about possible suicidal thoughts or Encourages the client to discuss feelings of possible suicidal
plans.4244 intent.
Refer the client for psychiatric assessment and treatment if risk Places the client in contact with necessary resources for treatment.
for suicide is determined to be present.41,44
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Consult with and/or refer the patient to assistive resources such Utilization of existing services is an efcient use of resources.
as caregiver support groups as needed.
Monitor the client and family closely for warning signs or risks Understanding helps promote a sense of control and order.
for suicide.
Consider all threats seriously.
When a threat is made, do not leave the client alone for any Minimizes risk of a suicide attempt.
period of time.
Ask direct questions about intent: Helps determine the seriousness and lethality of the suicide plan.
Have you thought about killing yourself? Indicates to the client that you take him or her seriously and are
Have you thought about how and when you might do this? willing to help.
What can I or we do to help you through this time?
Assist the family or caregivers in removing the most lethal Although it is not possible to remove all potentially destructive
means of suicide, such as weapons and medications. items, removal of the most lethal items reduces the likelihood of
an attempt or successful effort.
Develop a written no-suicide contract with the client; i.e., the Allows time for intervention should the client decide to attempt
client agrees that he or she will not hurt or kill himself or herself suicide. Provides the client with a sense of responsibility to
during a specic time period; that if such thoughts occur he or another and a sense that he or she is important to others.
she will contact the nurse or other involved person; and if the
contact person is not immediately available, the client will
continue trying to reach him or her.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., states Counseling Reassess using initial assessment factors.
has helped; has had family get rid of
gun and medications; no longer wants
to die, states I really have a lot to live for.
Record RESOLVED. (May wish to use
CONTINUE until patient discharged from
your service.) Delete nursing diagnosis,
expected outcome, target date, and No Is diagnosis validated?
nursing actions.
No Finished
Copyright 2002 F.A. Davis Company
CHAPTER 12
Value-Belief Pattern
681
Copyright 2002 F.A. Davis Company
system but must also recognize his or her own beliefs and values. This is a conformist stage, where peers and their values become
The nurse must know about or develop resources to assist with un- most important. Inuences from earlier stages are carried
derstanding the different beliefs and religious practices of groups within as reference points by which beliefs, values, and actions
encountered in practice settings. Further understanding and as- are valued, and actions are validated and sanctioned.
sessment of a patients beliefs can be ascertained by asking ques- 4. Individuative-Reexive The individual begins to construct and
tions such as Do you have a faith community? or Which beliefs maintain his or her own identity, autonomy, and faith, without re-
and practices are important to you?5 lying on others. The sense of self is now reciprocal with a faith out-
Studies have shown that the value of specic rituals such as look or worldview that negotiates between self and signicant oth-
prayer to the individuals who practice them is not affected by the ers. One knows he or she is different from others, and his or her
fact that they can or cannot be proved scientically.6 The impact of views and faith are vulnerable to challenge and change.
values and beliefs is best described by the following quote: 5. Paradoxical-Consolidative Many previous dimensions that
were formally suppressed or ignored are integrated. One be-
When as much emphasis is placed on the symbolic and intuitive as comes open to the voices of ones most inner self. There is a com-
on the analytical, consciousness develops more fully. The expansion ing to terms with ones social unconsciousness: the myths,
of consciousness is what life and, therefore, health is all about and norms, ideal images, and prejudices that have, until now,
health can coexist with illness and even encompass it as a mean-
formed ones life. One can see injustice, because of an expanded
ingful aspect.4
awareness of the demands of justice and the implications of
This can be seen in those individuals who consider suffering, ill- those demands.
ness, and even death as having meaning in life or as Gods will. 6. Universalizing The individual at this stage becomes a disci-
Many individuals believe that the only value of life, and the source plined activist. He or she exhibits qualities that shake the usual
of strength and power, is the will of the individual and that there is no criteria of normalcy. He or she leads and embraces strategies of
need for assistance from the outside. This focus has been described as nonviolent suffering and of ultimate respect for life. They often
a persons authority within himself.6 This focus may actually revolve become martyrs to the visions they incarnate.2
around work, physical activity, or self 6I can do anything I want to
Another study10 provides insights regarding the interactive
when I want to. Three predominant indicators have been listed that
process of caring as it relates to spiritual needs. Trust, meaningful
must be considered when judging the value of continued life: mental
support systems, and a respect for personal beliefs were identied
capacity, physical capacity, and pain.7 This would indicate that life, in
by participants as central to care.
and of itself, is not intrinsically valuable to the possessor of it; instead,
Because of the conscious, subconscious, and unconscious com-
it is the quality of conscious life that is important.
ponents of the value-belief system, nurses must be continually alert
In one phenomenological study8 of spirituality, the constituents
for disruptions in the system. There is a need to be aware that every
of spirituality, as reported by the study subjects, were described and
individual expresses disruptions in spirituality differently.11 Some
included (1) realization of humanity of self or valued other; (2) event
withdraw, some become more religious, and some become angry
of nonhuman intervention; (3) receiving divine intervention; (4) vis-
and deant. Nurses need to be cognizant of not only the patients
ceral knowing; (5) willingness to sacrice; (6) physical sensations;
spiritual beliefs but also the stage of spiritual development in which
(7) a personal experience; (8) a reality experience; (9) not easily ex-
the patient and nurse are. This will affect and determine not only
plained; and (10) different from or more than daily experience. In
the needs and concerns of the patients but how the nurse will ap-
1981, Fowler1 described his faith development theory, which was
proach the patient to care for those needs and concerns. This aware-
inuenced by the work of Piaget and Kolberg. Fowler describes faith
ness of and respect for the impact and inuence values and beliefs
as not always religious in its content or context but a persons or
have on the patient cannot be overemphasized in planning and pro-
groups way of moving into the force eld of life. It is our way of nd-
viding high-quality care for the patient.
ing coherence in and giving meaning to the multiple forces and re-
lations that make up our lives. Fowler described the experience of
spirituality in different stages of the life cycle. He states that one tran-
sitions from one stage to another, some fast and some slow, and that Developmental Considerations
it is not a simple change of mind or even a conscious movement The geographic, social, political, and home environment in which
from one phase to another, and that it can be a long and painful one lives has a major effect on how a person develops, how he or
process. Six states of faith are recognized by Fowler: she will view health, and how spirituality, values, and beliefs are
1. Intuitive-Projective This stage is characterized by experienc- formulated. The values a person holds inuence all facets of life.
ing the world as a child, uid and full of novelty, with a rudi- How one perceives the world about him or her, as well as his or her
mentary awareness of self as the center of the universe. Preop- basic philosophy, guides all interactions with others and ultimately
erational reasoning and judgment are employed by people in reects a persons individuality.
this stage. There is no reasoning or logic to thought; therefore, Fowler, in describing his developmental stages of faith, states he
the capacity for taking the role or perspective of others is ex- has found, regardless of chronologic age, adults and adolescents in
tremely limited. stages 2 and 3 and some adults in all stages. But persons are usu-
2. Mythic-Literal People in this stage can separate real from unreal ally found in the various stages as shown in the parentheses at the
on the basis of experience, and therefore the world becomes more end of each developmental stage in the following narrative.
linear and orderly than in stage 1. This is accompanied by a pri-
vate world of speculation, fantasy, and wonder. Bounds of the so- INFANT
cial world widen, and the questioning of good and evil is begun.
Often these thoughts, which can be reassuring, hopeful, or full of The infant is totally dependent on the parents and those about him or
terror and fear, are symbolized in dreams and daydreams.1,9 her and is busy building trust or mistrust.12 Unable at this age to form
3. Synthetic-Conventional One begins to structure the world values or distinguish spirituality, the infant is a mirror image of those
and the environment in interpersonal terms. The individual con- about him or her. The parents method of interaction, communica-
structs an image of self as seen by others and becomes aware that tion, and fulllment of the emotional and physiologic needs of the in-
others are performing the same operations in their relationships. fant forms the basis for value development. (Fowlers stage 1)
Copyright 2002 F.A. Davis Company
TODDLER AND PRESCHOOLER Spiritual Distress Disruption in the life principle that pervades a
persons entire being and that integrates and transcends ones bio-
The toddler imitates those about him or her: parents, siblings, and logic and psychosocial nature.
other adults. The toddler develops by mimicking observed behavior
and receiving either positive or negative reinforcement. Values begin
to form as the toddler begins to become aware of others and to inter- NANDA TAXONOMY: DOMAIN 10LIFE
act with those around him or her. Values become known to individ- PRINCIPLES; CLASS 3VALUE/BELIEF/ACTION
uals through the process of social cognition, which begins in early CONGRUENCE
childhood. This arises not from objects nor the subject but from the NIC: DOMAIN 3BEHAVIORAL; CLASS RCOPING
interaction between the subject and those objects.13 (Fowlers stage 1) ASSISTANCE
SCHOOL-AGE CHILD NOC: DOMAIN VPERCEIVED HEALTH;
CLASS UHEALTH AND LIFE QUALITY
The school-age child begins to be inuenced by peers outside the
family structure and begins to question and make choices. The
school-age child actively participates in his or her own moral de- DEFINING CHARACTERISTICS15
velopment. Individual reasoning develops through various stages, A. Risk for Spiritual Distress (Risk Factors)
beginning in the school-age years.14 Play is the major mechanism 1. Energy-consuming anxiety
of learning throughout the school-age years. (Fowlers stage 2) 2. Low self-esteem
3. Mental illness
ADOLESCENT 4. Blocks to self-love
5. Poor relationships
The adolescent searches for his or her own identity and begins to
6. Physical or psychological stress
practice values that are separate and yet congruent with his or her
7. Substance abuse
family unit. The adolescent is constantly questioning, trying, and
8. Loss of loved one
searching for the truth of life and for his or her identity in the
9. Natural disasters
scheme of things. He or she sees values as being either black or
10. Situational losses
white, and there can be no overlapping. The adolescent is still
11. Maturational losses
struggling with his or her own independence and formulating his or
12. Inability to forgive
her own values, beliefs, and spirituality. (Fowlers stages 2 and 3)
B. Spiritual Distress
1. Expresses concern with meaning of life or death and/or
YOUNG ADULT belief systems
Young adults are constantly examining, reformulating, and chang- 2. Questions moral or ethical implications of therapeutic
ing their values, beliefs, and spirituality. Often they change com- regimen
pletely the values and beliefs they developed during adolescence, 3. Description of nightmares or sleep disturbances
although it is important to note that they often keep the basic val- 4. Verbalizes inner conict about beliefs
ues and beliefs they learned during their young years with their 5. Verbalizes concern about relationship with deity
families. (Fowlers stages 3 and 4) 6. Unable to participate in usual religious practices
7. Seeks spiritual assistance
8. Questions meaning of suffering
ADULT
9. Questions meaning of own existence
Adults usually strengthen the values and beliefs they have formed ac- 10. Displacement of anger toward religious representatives
cording to their life experiences. The adult is continually exploring and 11. Expresses anger toward God
trying to see whether his or her value system ts within his or her 12. Alteration in behavior or mood evidenced by anger, crying,
lifestyle. They are busy teaching children the values and beliefs that they withdrawal, preoccupation, anxiety, hostility, apathy, and
wish their children to adopt for their lives. (Fowlers stages 4 and 5) so forth
13. Gallows humor (inappropriate humor in a grave situation)
OLDER ADULT
Older adults nd great solace in their spirituality and the values and RELATED FACTORS15
beliefs they have formed through a lifetime. In general, the older A. Risk for Spiritual Distress
adult continues to use the values, beliefs, and spiritual patterns The risk factors also serve as the related factors.
adopted in adulthood.5 (Fowlers stages 5 and 6) B. Spiritual Distress
1. Challenged belief and value system, for example, as a re-
sult of moral or ethical implications of therapy or intense
suffering
APPLICABLE NURSING DIAGNOSES 2. Separation from religious or cultural ties
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Assist the patient to identify and dene his or her values, Claries values and beliefs, and helps the patient understand
particularly in relation to health and illness, through the use impact of values and beliefs on health and illness.
of value clarication techniques such as sentence completion,
rank-ordering exercises, and completion of health-value
scales.
Demonstrate respect for and acceptance of the patients values Spiritual values and beliefs are highly personal. A nurses attitude
and spiritual system by not judging, moralizing, arguing, or can positively or negatively inuence the therapeutic relationship.
advising changes in values or religious practices.
Adapt nursing therapeutics as necessary to incorporate values Maintains and respects the patients preferences during
and religious beliefs, e.g., diet, administration of blood or blood hospitalization.
products, or rituals.
Schedule appropriate rituals as necessary, e.g., baptism, Provides comfort for the patient.
confession, or communion.
Arrange visits from support persons, e.g., chaplain, pastor, Each offers good listening skills that promote comfort and reduce
rabbi, priest, or prayer group, as needed. anxiety.
Provide privacy for religious practices and rituals as necessary. Allows for expression of religious practices.
Encourage the family to bring signicant symbols to the patient, Promotes comfort.
e.g., Bible, rosary, or icons, as needed.
Plan to spend at least 15 min twice a day at [times] with the Promotes mutual sharing, and builds a trusting relationship.
patient to allow verbalization, questioning, counseling, and
support on a one-to-one basis.
Assist the patient to develop problem-solving behavior through Involves the patient in self-management activities. Increases
practice of problem-solving techniques at least twice daily at motivation.
[times] during hospitalization.
Child Health
ACTIONS/INTERVENTIONS RATIONALES
Support the patient in attaining or maintaining spiritual integrity Openness affords trust as the child grapples with the meaning of
according to specic identied needs and developmental level. such stressors as illness and death.
Remember to pay attention to the parental dyads value-belief
preferences:
(continued)
Copyright 2002 F.A. Davis Company
(continued)
ACTIONS/INTERVENTIONS RATIONALES
Allow for appropriate privacy.
Allow time for self-reection.
Allow time for prayer and practice of worship as permitted.
Support the child in expressing feelings about spiritual
distress and related factors through use of open-ended
questions and providing time for this at least twice a day at
[times].
Act as advocate for the child and family when they are
expressing differing beliefs from that of the staff, institution,
or signicant others.
Answer value-belief-related questions honestly according to the Sensitivity to needs within legal domains regarding appropriate
patients developmental level and after conferring with the standards of care honors the childs rights and attaches value to
parents. the familys cultural wishes.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
Allow the mother and family to express feelings at the Allows the family to receive religious and social support as a
less-than-perfect pregnancy outcome:16 means of coping.
Stillborn or infant death:
(1) Provide time for the mother and family to see, hold, and
take pictures of the infant if so desired.
(2) Provide quiet, private place where the mother and family
can be with the infant.
(3) Arrange for religious practices requested, e.g., baptism
or other rituals.
(4) Contact religious or cultural leader as requested by the
mother or family.
(5) Refer to appropriate support groups within the
community.
(6) Do legacy building, e.g., cap, bracelets, certicate of life,
and footprints.17
Spontaneous abortion:
(1) Provide the patient with factual information regarding Assists in reducing guilt, blame, etc.
etiology of spontaneous abortion.
(2) Encourage verbal expressions of grief.
(3) Allow expression of feelings such as anger.
(4) Do legacy building, e.g., cap, bracelets, certicate of life,
and footprints.17
(5) Provide information on miscarriage and grief.
(6) Contact religious or cultural leader as requested by the
patient.
(7) Provide referrals to appropriate support groups within Provides information and support for the family.
the community.
Less-than-perfect baby, e.g., sick baby or infant with
anomaly:
(1) Provide quiet, private place for the mother and family to
visit with the infant.
(2) Encourage verbalization of fears and asking of any
question by providing time for one-to-one interactions at
least twice a day at [times].
(3) Encourage touching and holding of the infant by the
mother and family.
(4) Teach methods of caring for the infant, e.g., special
feeding techniques.
(5) Teach methods of coping with the stress connected with
caring for the infant, e.g., planned alone time for
relaxation techniques.
(6) Assign one staff member to care for both the mother and
infant.
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
ACTIONS/INTERVENTIONS RATIONALES
Remove items from the environment that increase problem Environment will assist the client in demonstrating appropriate
behavior (list specic items for each client, e.g., Bible or coping behaviors, which increases opportunities for succeeding
religious pictures). with new coping behaviors. Success provides reinforcement, which
encourages positive behavior and enhances self-esteem.
Restrict visitors who increase problem behavior for the client. Promotes the clients sense of control.
Discuss with the family and other frequent visitors the necessity
of not discussing the problem ideas with the client.
Request consultation from religious leader who has had Meets the clients spiritual needs in a constructive manner.
education and experience in assisting clients to cope with this
type of spiritual distress.
Do not discuss with the client belief systems that are related to These discussions only serve to reinforce the clients
problem behavior (state here specically what that content is). misconceptions.
Do not argue with the client about religious belief system or This would reinforce the dysfunctional belief system.
behaviors that evolve from this system.
Do not joke with the client about belief system or behavior that Protects the clients self-esteem at a time when it is most
evolves from this system. vulnerable.
Spend time with the client when themes of conversation are not Presence of the nurse, at this time, provides reinforcement for
related to the problem behavior. this behavior, which encourages the positive behavior and
enhances self-esteem.
Limit topics of conversation to daily activities or situations that Environmental structure helps the client focus away from problem
do not include religious beliefs. areas, which supports his or her efforts to enlist more appropriate
coping behaviors.
Provide activities that decrease client time alone to reect on the Provides the client with opportunities to practice alternative coping
problem beliefs. Suggested activities include: behaviors in a supportive environment.
Physical exercise such as walks, bicycle riding, swimming, or
exercise classes
Group activities such as board games, meal preparation,
sports, or arts and crafts
Copyright 2002 F.A. Davis Company
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Encourage use of reminiscence to aid the patient in examining Assists the patient in nding meaning in life experiences and ego
life.18 integrity.
Discuss with the patient possible sources of spiritual distress, Enables the patient to identify problem areas and potential
and use problem-solving process as indicated. correctable measures to ameliorate distress.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
ACTUAL
Involve the client and family in planning, implementing, and Family and client involvement enhances the effectiveness of the
promoting spiritual well-being through: interventions.
Arranging family conferences to discuss spiritual values.
Assisting with mutual goal setting for the client and family to
enhance spiritual well-being of the client and family, such as
personal prayer, interactions with clergy, family, and nurses
to nd meaning during illness.19
Assigning family members to specic tasks that assist in
maintaining spiritual well-being, e.g., support person for the
client, companionship in meeting mutual goals, prayer,
meditation, reading Scripture, etc.16
Interviewing designed to provide opportunities for
expression of spiritual needs.19
Assist the client to identify factors contributing to spiritual Identication of contributing factors provides the opportunity for
distress, e.g., signicant life experiences, treatment prescribed planning designed to decrease these factors.
by health care team, or inability to perform spiritual rituals.
Assist the client and family in lifestyle adjustments that may be Lifestyle changes require change in behavior. Self-evaluation and
required, e.g., diet, environmental changes, or hygiene practices. support facilitate these changes.
Assist the client and family in expressing spirituality in the Facilitates expression of spirituality and access to spiritual support
home in as normal a fashion as possible; e.g., help arrange for systems.
priest or pastoral visits, help arrange for visits from church
friends, respect schedules necessary for worship, prayer, or
meditation.
Refer to appropriate assistive resources as indicated. Challenges to ones value system may require long-term follow-up.
Use of the network of existing community services provides for
effective utilization of resources.
RISK FOR
Assist the client in a search for meaning of the clients life as it The search for meaning is a common task of the human
has been lived. This can be accomplished by asking the client experience.20,21
questions, such as:
If you had your life to live over again, what would you like
to be different and what the same?
What does it mean to you that this has happened?
Recognize that spiritual strength comes from many secular The concept of God is different to all people, and spirituality is
sources, such as nding hope and relationships with other derived from sources unique to each individual.20,21
people.
Listen without judging when clients share spiritual concerns. Talking in itself is therapeutic, and nonjudgmental listening may
Active listening requires attention to and focus on the client. enable a client to work through difcult spiritual issues. Silence,
presence, and concentration are signicant spiritual tools.
Accept the client no matter what his or her understanding or Enhances the trust relationship between nurse and the client.
experience of God.
Respect the clients wishes about when he or she chooses to Enhances the trust relationship between nurse and the client.
discuss issues of spirituality.20,21
Avoid giving advice, offering solutions, or platitudes.20,21 Often a clients questions about spiritual issues are ways of
beginning a difcult conversation, rather than a search for answers
from a nurse.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., has identified Sunday Reassess using initial assessment factors.
School teacher and church youth director
as usable support systems; both have
visited and are willing to assist. Record
RESOLVED. Delete nursing diagnosis,
expected outcome, target date, and
nursing actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
DEFINING CHARACTERISTICS15
EXPECTED OUTCOME
1. Inner Strengths: A sense of awareness, self-consciousness, sacred
source, unifying force, inner core, and transcendence Will exhibit majority [percent number] of dening characteristics
2. Unfolding Mystery: Ones experience about lifes purpose and for diagnosis by [date].
meaning, mystery, uncertainty, and struggles
3. Harmonious Interconnectedness: Harmony, relatedness, and TARGET DATES
connectedness with self, others, Higher Power or God, and the
environment The target date for this diagnosis will be highly individualized. An
appropriate initial date to check progress would be 10 to 14 days.
RELATED FACTORS15
None given.
Adult Health
ACTIONS/INTERVENTIONS RATIONALES
Establish a trusting relationship. A trusting relationship assists the patient to express his or her
feelings to the nurse.
Provide in-depth spiritual assessment. These are all spiritual care practices that enhance spirituality.2224
Convey technical competence.
Act as facilitator among the family, clergy, and other providers.
Be present: touch, make eye contact, and use appropriate facial
expressions.
Treat the patient as a unique individual.
Inquire about religion, values, relationships, transcendence, Spirituality is expressed in all these areas.25
affective feeling, communication, and spiritual practices.
Support and enhance the patients spirituality.
Pray for and with the patient. These are all spiritual care practices.
Read Bible with the patient.
Refer to chaplain, clergy, or spiritual advisor.
Provide with religious materials.
Serve as a therapeutic presence.
Listen and talk to the patient.
If possible, allow the patient to interact and/or care for other Provides expansion of personal boundaries through connectedness.
patients. Provides a sense of wholeness and well-being. Person may be ill
and still be healthy in terms of spirituality, as spirituality
provides the patient with the capacity for health through
transcendence of ordinary boundaries and various modes of
connectedness.26
(continued)
Copyright 2002 F.A. Davis Company
Child Health
NOTE: Consider all actions listed for Adult Health, but modify them to be developmentally appro-
priate. When the infant or child is incapable of expressing spiritual preferences or indices, refer the
child to parents or staff or advocacy as deemed appropriate.
ACTIONS/INTERVENTIONS RATIONALES
Allow 30 min each shift for expression of feelings about current Feelings regarding current status will provide opportunity to
health status and/or offer structured observation of the infant, know spiritual factors valued.
child, or parents to offer insight into thoughts relevant to
current status.
Allow for component of play therapy to provide spiritual data. Play facilitates meaningful interaction for children and may best
afford insights into thought processes.
Abide by the familys wishes in times of spiritual need and as Trust will be afforded to enhance current spiritual well-being
part of regular care to degree possible. when it is shown to have value.
Incorporate spirituality into local support system by encouraging Valuing of community potentials increases likelihood of spiritual
donations of time, reading materials, videos, art supplies, etc., support, especially for young.
with age-appropriate materials for all levels of development.
Womens Health
ACTIONS/INTERVENTIONS RATIONALES
NOTE: All the actions under Spiritual Distress can apply here as
well as the following:
Allow the woman and her family to direct the spiritual care By allowing the patient to express her own beliefs and values,
needed when possible. strengths, and relationships, great insight into how health care
providers can provide high-quality care to the whole person can
emerge. This can form the basis of care or support to patients.
Be available and willing to call whatever spiritual advisor the
woman and family wish.
(continued)
Copyright 2002 F.A. Davis Company
Psychiatric Health
Refer to Adult Health interventions.
Gerontic Health
ACTIONS/INTERVENTIONS RATIONALES
Determine availability of religious services or ceremonies for the If the patient attends religious services, he or she may need
patient. information about what services are offered. The number of
active, participating church members is highest in the older adult
group.
Coordinate, as needed, transportation to formal services or Aging physical changes may interfere with access to services.
visits from religious representatives.
Provide time for religious activities or personal time for Depending on the care setting and care needs, it may be difcult
meditation or contemplation. to incorporate activities or personal time, and the patient may be
hesitant to make the need known.
Establish ongoing relationship with the patient that fosters trust Provides an opportunity to gradually reveal self and nurture
and sharing. spiritual growth for the caregiver and the care recipient.
Encourage life review or reminiscing to assist the older patient Offers insight into coping ability and needs.
in identication of past stressors and coping skills.
Discuss how aging has changed the patient, from his or her Enhances self-worth and problem-solving skills the older patient
perspective, and what those changes have meant to the patient. possesses. Promotes developmentally appropriate reection.
Discuss spiritual care needs with the patient, and identify Clergy are frequently used as personal counselors by older adults.
preferred spiritual advisor, counselor, or resource for the patient.
Offer opportunities to pray with the older patient, if you are Health-related prayer is considered a source of comfort to many
comfortable in so doing. older patients.
Home Health
ACTIONS/INTERVENTIONS RATIONALES
Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention.
strategies to enhance spiritual well-being:
Identify values and beliefs.
Develop lifestyle choices that support values and beliefs.
Explore meaning of spirituality to self and family.
Identify actions and behaviors that express spirituality.
Copyright 2002 F.A. Davis Company
Yes No
Record data, e.g., exhibits all of defining Reassess using initial assessment factors.
characteristics. Record RESOLVED.
Delete nursing diagnosis, expected
outcome, target date, and nursing
actions.
No Is diagnosis validated?
No Finished
Copyright 2002 F.A. Davis Company
APPENDIX A
693
Copyright 2002 F.A. Davis Company
APPENDIX B
Demographic Data
Name: __________________________________________________________________________________
Vital Signs
Blood Pressure: Left arm _______ ; Right arm _______ ; Sitting __ Standing __ Lying down __
Weight: _______ pounds, _______ kilograms; Height: ___ feet ___ inches, _____ meters
Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here:
________________________________________________________________________________________
SUBJECTIVE
1. How would you describe your usual health status? Good __ Fair __ Poor __
2. Are you satised with your usual health status? Yes ___ No ___
Source of dissatisfaction _________________________________________________________________
3. Tobacco use? No ___ Yes ___ Number of packs per day? _____________________________________
4. Alcohol use? No ___ Yes ___ How much and what kind? ______________________________________
694
Copyright 2002 F.A. Davis Company
APPENDIX B 695
5. Street drug use? No ___ Yes ___ What and how much? _____________________________________
6. Any history of chronic diseases? No ___ Yes ___ Describe ____________________________________
____________________________________________________________________________________
7. Immunization History: Tetanus ______ ; Pneumonia ______ ; Inuenza ______ ;
MMR ______ ; Polio ______ ; Hepatitis B ______ ; Hib ______
8. Have you sought any health care assistance in the past year? No ___ Yes ___
If yes, why? __________________________________________________________________________
9. Are you currently working? Yes ___ No ___ How would you rate your working conditions (e.g., safety,
noise, space, heating, cooling, water, ventilation)?
Excellent ____ Good ____ Fair ____ Poor ____ Describe any problem areas __________________
____________________________________________________________________________________
10. How would you rate living conditions at home? Excellent ___ Good ___ Fair ___ Poor ___
Describe any problem areas ______________________________________________________________
11. Do you have any difculty securing any of the following services?
Grocery store? Yes ___ No ___ ; Pharmacy? Yes ___ No ___ ;
Health care facility? Yes ___ No ___ ; Transportation? Yes ___ No ___ ;
Telephone (for police, re, ambulance, etc.)? Yes ___ No ___
If any difculties, note referral here _______________________________________________________
12. Medications (over-the-counter and prescriptive)
NAME DOSAGE AMT. TIMES/DAY REASON TAKING AS ORDERED
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
_____________________________________________________________________ Yes ___ No ___
13. Have you followed the routine prescribed for you? Yes ___ No ___
Why not? ____________________________________________________________________________
14. Did you think this prescribed routine was the best for you? Yes ___ No ___
What would be better? _________________________________________________________________
15. Have you had any accidents/injuries/falls in the past year? No ___ Yes ___
Describe _____________________________________________________________________________
16. Have you had any problems with cuts healing? No ___ Yes ___ Describe__________________________
____________________________________________________________________________________
17. Do you exercise on a regular basis? No ___ Yes ___ Type and Frequency __________________________
____________________________________________________________________________________
18. Have you experienced any ringing in the ears? Right ear: Yes ___ No ___
Left ear: Yes ___ No ___
19. Have you experienced any vertigo? Yes ___ No ___ How often and when? _________________________
____________________________________________________________________________________
20. Do you regularly use seat belts? Yes ____ No ____
21. For infants and children, are car seats used regularly? Yes ____ No ____
22. Do you have any suggestions or assistance requests for improving your health?
No ___ Yes _________________________________________________________________________
23. Do you do (breast/testicular) self-examination? No ___ Yes ___
How often? ___________________________________________________________________________
24. Were you or your family able to meet all your therapeutic needs? Yes ___ No ___
25. Are you scheduled for surgery? Yes ___ No ___
26. Have you recently had surgery? No ___ Yes ___ Date __________
Copyright 2002 F.A. Davis Company
696 APPENDIX B
OBJECTIVE
APPENDIX B 697
10. Throat: Enlarged tonsils? No ___ Yes ___ Location __________________________________________
Tenderness? No ___ Yes ___ Exudate on tonsils? No ___ Yes ___ Color _________________________
Uvula midline? No ___ Yes ___
11. Neck: Any enlarged lymph nodes? No ___ Yes ___ Location and size ____________________________
____________________________________________________________________________________
12. General Appearance
a. Hair _____________________________________________________________________________
b. Skin _____________________________________________________________________________
Does the patient exhibit any eczema? No ___ Yes ___ Where? _________________________________
c. Nails ____________________________________________________________________________
d. Body Odor ________________________________________________________________________
13. Does the patient have a history of multiple surgeries or a history of reaction to latex?
No ___Yes ___ Which one? ___ Multiple surgeries ___ Reaction to latex
14. Is the patients surgical incision healing properly? N/A ___ Yes ___ No ___
Describe ___________________________________________________________________________
Nutritional-Metabolic Pattern
SUBJECTIVE
1. Any weight gain in last 6 months? No ___ Yes ___ Amount ___________________________________
2. Any weight loss in last 6 months? No ___ Yes ___ Amount ____________________________________
3. Would you describe your appetite as: Good ___ Fair ___ Poor ___
4. Do you have any food intolerances? No ___ Yes ___ Describe __________________________________
____________________________________________________________________________________
5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as
those that patient restricts voluntarily; for example, to prevent atus.)
No ___ Yes ___ What __________________________________________________________________
6. Describe an average days food intake for you (meals and snacks).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. Describe an average days uid intake for you. _______________________________________________
____________________________________________________________________________________
8. Describe food likes and dislikes. __________________________________________________________
____________________________________________________________________________________
9. Would you like to: Gain weight? ___ Lose weight? ___ Neither ___
10. Any problems with:
a. Nausea? No ___ Yes ___ Describe _____________________________________________________
b. Vomiting? No ___ Yes ___ Describe ____________________________________________________
c. Swallowing? No ___ Yes ___ Describe __________________________________________________
d. Chewing? No ___ Yes ___ Describe ____________________________________________________
e. Indigestion? No ___ Yes ___ Describe __________________________________________________
11. Would you describe your usual lifestyle as: Active ___ Sedate ___
12. Do you have any chronic health problems? No ___ Yes ___ Describe ____________________________
____________________________________________________________________________________
698 APPENDIX B
14. Are you having any problems with breastfeeding? No ___ Yes ___
Describe ___________________________________________________________________________
OBJECTIVE
1. Skin Examination
a. Warm ____ Cool ____ Moist ____ Dry ____
b. Lesions? No ___ Yes ___ Describe _____________________________________________________
c. Rash? No ___ Yes ___ Describe _______________________________________________________
d. Turgor: Firm ____ Supple ____ Dehydrated ____ Fragile ____
e. Color: Pale ____ Pink ____ Dusky ____ Cyanotic ____ Jaundiced ____ Mottled ____
Other ____________________________________________________________________________
2. Mucous Membranes
a. Mouth
(1) Moist ____ Dry ____
(2) Lesions? No ___ Yes ___ Describe _________________________________________________
(3) Color: Pale ____ Pink ____
(4) Teeth: Normal ___ Abnormal ___ Describe _____________________________________________
(5) Dentures? No ___ Yes ___ Upper ____ Lower ____ Partial ____
(6) Gums: Normal ___ Abnormal ___ Describe __________________________________________
(7) Tongue: Normal ___ Abnormal ___ Describe _________________________________________
b. Eyes
(1) Moist ____ Dry ____
(2) Color of conjunctivae: Pale ____ Pink ____ Jaundiced ____
(3) Lesions? No ___ Yes ___ Describe _________________________________________________
3. Edema
a. General? No ___ Yes ___
Describe _________________________________________________________________________
__________________________________________________________________________________
Abdominal Girth: _______inches; Not measured ____
b. Periorbital? No ___ Yes ___ Describe ____________________________________________________
c. Dependent? No ___ Yes ___ Describe ___________________________________________________
Ankle Girth: Right _____ inches; Left _____ inches; Not measured ____
4. Thyroid: Normal ____ Abnormal ____ Describe ____________________________________________
5. Jugular vein distention? No ___ Yes ___
6. Gag Reex: Present ___ Absent ___
7. Can the patient move self easily (turning, walking)? Yes ___ No ___
Describe limitations ___________________________________________________________________
8. Upon admission was the patient dressed appropriately for the weather? Yes ___ No ___
Describe ____________________________________________________________________________
Elimination Pattern
SUBJECTIVE
APPENDIX B 699
b. Same time each day? No ___ Yes ___
2. Has the number of bowel movements changed in the past week? No ___ Yes ___
Increased ___ Decreased ___
3. Character of stool:
a. Consistency: Hard ____ Soft ____ Liquid ____
b. Color: Brown ____ Black ____ Yellow ____ Clay colored____
c. Bleeding with bowel movements? No ___ Yes ___
4. History of constipation? No ___ Yes ___ How often ________________________________
Use bowel movement aids (laxatives, suppositories, diet)? No ___ Yes ___
Describe _____________________________________________________________________________
5. History of diarrhea? No ___ Yes ___ When __________________________________________________
6. History of incontinence? No ___ Yes ___
Related to increased abdominal pressure (coughing, laughing, sneezing)? No ___ Yes ___
7. History of recent travel? No ___ Yes ___ Where ______________________________________________
8. Usual voiding pattern:
a. Frequency (times/day) ________ Decreased ___ Increased ___
b. Change in awareness of need to void? No ___ Yes ___ Increased ___ Decreased ___
c. Change in urge to void? No ___ Yes ___ Increased ___ Decreased ___
d. Any change in amount? No ___ Yes ___ Decreased ___ Increased ___
e. Color: Yellow ____ Smoky ____ Dark ____
f. Incontinence? No ___Yes ___ When ____________________________________________________
Difculty holding voiding when urge to void develops? No ____ Yes ____
Have time to get to bathroom? Yes ____ No ____
How often does problem of reaching the bathroom occur? ___________________________________
g. Retention? No ___ Yes ___ Describe ____________________________________________________
h. Pain/burning? No ___ Yes ___ Describe __________________________________________________
i. Sensation of bladder spasms? No ___ Yes ___ When ________________________________________
OBJECTIVE
1. Auscultate abdomen.
a. Bowel Sounds: Normal ____ Increased ____ Decreased ____ Absent ____
2. Palpate abdomen.
a. Tender? No ___ Yes ___ Where? _______________________________________________________
b. Soft? Yes ___ No ___ ; Firm? Yes ___ No ___
c. Masses? No ___ Yes ___ Describe _______________________________________________________
d. Distention (include distended bladder)? No ___ Yes ___ Describe _____________________________
___________________________________________________________________________________
e. Overow urine when bladder palpated? Yes ___ No ___
3. Rectal Exam
a. Sphincter tone: Describe ______________________________________________________________
b. Hemorrhoids? No ___ Yes ___ Describe _________________________________________________
c. Stool in rectum? No ___ Yes ___ Describe ________________________________________________
d. Impaction? No ___ Yes ___ Describe ____________________________________________________
e. Occult blood? No ___ Yes ___
4. Ostomy present? No ___ Yes ___ Location __________________________________________________
Copyright 2002 F.A. Davis Company
700 APPENDIX B
Activity-Exercise Pattern
SUBJECTIVE
1. Using the following Functional Level Classication, have the patient rate each area of self-care. (Code
adapted by NANDA from Jones, E, et al: Patient Classication for Long-Term Care: Users Manual, HEW
Publication No. HRA-74-3107. November, 1974.)
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependent, does not participate in activity
Feeding _____; Bathing/hygiene _____; Dressing/grooming _____;
Toileting _____; Ambulation _____; Care of home ______; Shopping ____;
Meal preparation _____; Laundry _____; Transportation _____
2. Oxygen use at home? No ___ Yes ___ Describe ______________________________________________
3. How many pillows do you use to sleep on? ______
4. Do you frequently experience fatigue? No ___ Yes ___ Describe _________________________________
_____________________________________________________________________________________
5. How many stairs can you climb without experiencing any difculty (can be individual number or number
of ights)? ___________________________________________________________________________
6. How far can you walk without experiencing any difculty? ____________________________________
7. Any history of falls? No ___ Yes ___ How often? ____________________________________________
8. Has assistance at home for care of self and maintenance of home? No ___ Yes ___
Who _______________________________________________________________________________
If no, would like to have or believes needs to have assistance? No ___ Yes ___
With what activities? __________________________________________________________________
9. Occupation (if retired, former occupation) ________________________________________________
10. Describe your usual leisure time activities/hobbies. __________________________________________
____________________________________________________________________________________
11. Any complaints of weakness or lack of energy? No ___ Yes ___
Describe ____________________________________________________________________________
12. Any difculties in maintaining activities of daily living? No ___ Yes ___
Describe ____________________________________________________________________________
13. Any problems with concentration? No ___ Yes ___
Describe ____________________________________________________________________________
14. If in wheelchair, do you have any problems manipulating the wheelchair? No ___ Yes ___
Describe ____________________________________________________________________________
15. Can you move yourself from site to site with no problems? Yes ___ No ____
Describe ____________________________________________________________________________
OBJECTIVE
1. Cardiovascular
a. Cyanosis? No ___ Yes ____ Where? ____________________________________________________
b. Pulses: Easily palpable?
Carotid: Yes ___ No ___; Jugular: Yes ___ No ___; Temporal: Yes ___ No ___;
Radial: Yes ___ No ___; Femoral: Yes ___ No ___; Popliteal: Yes ___ No ___;
Post tibial: Yes ___ No ___; Dorsalis pedis: Yes ___ No ___
c. Extremities
(1) Temperature: Cold ___ Cool ___ Warm ___ Hot ___
(2) Capillary Rell: Normal ___ Delayed ___
Copyright 2002 F.A. Davis Company
APPENDIX B 701
(3) Color: Pink ___ Pale ___ Cyanotic ___ Other ___
Describe _______________________________________________________________________
(4) Homans sign? No ___ Yes ___
(5) Nails: Normal ___ Abnormal ___ Describe _____________________________________________
(6) Hair Distribution: Normal ___ Abnormal ___ Describe __________________________________
_______________________________________________________________________________
(7) Claudication? No ___ Yes ___ Describe ______________________________________________
d. Heart: PMI Location _________________________________________________________________
(1) Abnormal rhythm? No ___ Yes ___ Describe __________________________________________
_______________________________________________________________________________
(2) Abnormal sounds? No ___ Yes ___ Describe __________________________________________
_______________________________________________________________________________
2. Respiratory
a. Rate ________ ; Depth: Shallow ___ Deep ___ Abdominal ___ Diaphragmatic ___
b. Have the patient cough. Any sputum? No ___ Yes ___ Describe ______________________________
___________________________________________________________________________________
c. Fremitus? No ___ Yes ___
d. Any chest excursion? No ___ Yes ___ Equal ___ Unequal ___
e. Auscultate chest.
Any abnormal sounds (rales, rhonchi)? No ___ Yes ___
Describe ___________________________________________________________________________
f. Have the patient walk in place for 3 minutes (if permissible):
(1) Any shortness of breath after activity? No ___ Yes ___
(2) Any dyspnea? No ___ Yes ___
(3) BP after activity _____/______ in (right/left) arm
(4) Respiratory rate after activity ________
(5) Pulse rate after activity _______
3. Musculoskeletal
a. Range of motion: Normal ____ Limited ____ Describe ______________________________________
b. Gait: Normal ____ Abnormal ____ Describe ______________________________________________
c. Balance: Normal ____ Abnormal ____ Describe ___________________________________________
d. Muscle Mass/Strength: Normal ____ Increased ____ Decreased ____
Describe ___________________________________________________________________________
e. Hand Grasp: Right: Normal ____ Decreased ____
Left: Normal ____ Decreased ____
f. Toe Wiggle: Right: Normal ____ Decreased ____
Left: Normal ____ Decreased ____
g. Posture: Normal ____ Kyphosis ____ Lordosis ____
h. Deformities? No ___ Yes ___ Describe ___________________________________________________
i. Missing limbs? No ___ Yes ___ Where ___________________________________________________
j. Uses mobility assistive devices (walker, crutches, etc.)? No ___ Yes ___
Describe ___________________________________________________________________________
k. Tremors? No ___ Yes ___ Describe _____________________________________________________
l. Traction or casts present? No ___ Yes ___ Describe ________________________________________
m. Easily turns in bed? Yes ___ No ___ Describe _____________________________________________
4. Spinal cord injury? No ___ Yes ___ Level ___________________________________________________
5. Paralysis present? No ___ Yes ___ Where ___________________________________________________
6. Conduct developmental assessment. Normal ____ Abnormal ____ Describe _______________________
______________________________________________________________________________________
7. Responds appropriately to stimuli? Yes ___ No ___ Describe ____________________________________
______________________________________________________________________________________
8. Are there any abnormal movements? No ___ Yes ___ Describe __________________________________
____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
702 APPENDIX B
Sleep-Rest Pattern
SUBJECTIVE
1. Usual sleep habits: Hours/night ______ ; Naps? No ___ Yes ___ a.m. ____ p.m. ____
Feel rested? Yes ___ No ___ Describe ______________________________________________________
2. Any problems:
a. Difculty going to sleep? No ___ Yes ___
b. Awakening during night? No ___ Yes ___
c. Early awakening? No ___ Yes ___
d. Insomnia? No ___ Yes ___ Describe _____________________________________________________
3. Methods used to promote sleep: Medication? No ___ Yes ___ Name ______________________________
Warm uids? No ___ Yes ___ What _______________________________________________________
Relaxation techniques? No ___ Yes ___
OBJECTIVE
None
Cognitive-Perceptual Pattern
SUBJECTIVE
1. Pain
a. Location (have the patient point to area) _________________________________________________
b. Intensity (have the patient rank on scale of 010) ________
c. Radiation? No ____ Yes ____ To where? _________________________________________________
d. Timing (how often; related to any specic events) __________________________________________
____________________________________________________________________________________
e. Duration __________________________________________________________________________
f. What do you do to relieve pain at home? _________________________________________________
g. When did pain begin? ________________________________________________________________
2. Decision Making
a. Find decision making: Easy ____ Moderately easy ____ Moderately difcult ____ Difcult____
b. Inclined to make decisions: Rapidly ____ Slowly ____ Delay ____
c. Difculty choosing between options? Yes ___ No ___ Describe ________________________________
____________________________________________________________________________________
3. Knowledge Level
a. Can dene what current problem is? Yes ___ No ___
b. Can restate current therapeutic regimen? Yes ___ No ___
OBJECTIVE
1. Review sensory and mental status completed in Health PerceptionHealth Management Pattern.
2. Any overt signs of pain? No ___ Yes ___ Describe ____________________________________________
3. Any uctuations in intercranial pressure? Yes ___ No ___
Copyright 2002 F.A. Davis Company
APPENDIX B 703
OBJECTIVE
1. During assessment, the patient appears: Calm ____ Anxious ____ Irritable ____
Withdrawn ____ Restless ______
2. Did any physiologic parameters change: Face reddened? No ___ Yes ___
Voice volume changed? No ___ Yes ___ Louder ____ Softer ____
Voice quality changed? No___ Yes___ Quavering ____ Hesitation ____
Other _______________________________________________________________________________
3. Body language observed _________________________________________________________________
4. Is current admission going to result in a body structure or function change for the patient?
No ___ Yes ___ Unsure at this time ____
5. Is the patient expressing any fears about dying? No ___ Yes ___
6. Is the patient expressing worries about the impact of his or her death on his or her family and/or friends?
No ___ Yes ___ N/A ___
Role-Relationship Pattern
SUBJECTIVE
1. Does the patient live alone? Yes ___ No ____With whom ______________________________________
2. Is the patient married? Yes ___ No ___ ; Children? No ___ Yes ___ ; # of children __________________
Age(s) of children __________________________
Were any of the children premature? No ___ Yes ___ Describe __________________________________
_____________________________________________________________________________________
3. How would you rate your parenting skills: Not applicable ____
No difculty with ____ Average ____ Some difculty with ____
Describe _____________________________________________________________________________
_____________________________________________________________________________________
4. Any losses (physical, psychological, social) in past year? No ___ Yes ___
Describe _____________________________________________________________________________
5. How is the patient handling this loss at this time? ____________________________________________
_____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
704 APPENDIX B
6. Do you believe this admission will result in any type of loss? No ___ Yes ___
Describe ____________________________________________________________________________
7. Has the patient recently received a diagnosis related to a chronic physical or mental illness?
No ___ Yes ___
8. Is the patient verbally expressing sadness? No ___ Yes ___
9. Ask both the patient and family: Do you think this admission will cause any signicant changes in (the
patients) usual family role? No ___ Yes ___ Describe _________________________________________
____________________________________________________________________________________
10. How would you rate your usual social activities? Very active ____ Active ____ Limited ____ None ____
11. How would you rate your comfort in social situations? Comfortable ____ Uncomfortable ____
12. What activities/jobs, etc., do you like to do? ________________________________________________
____________________________________________________________________________________
13. What activities/jobs, etc., do you dislike doing? _____________________________________________
____________________________________________________________________________________
14. Does the person use alcohol or drugs? No ___ Yes ___ Kind ___________________________________
Amount ________________
15. Is the patient in the role of primary caregiver for another person? No ___ Yes ___
OBJECTIVE
1. Speech Pattern
a. Is English the patients native language? Yes ___ No ___
Native language is ______________ ; Interpreter needed? No ___ Yes ___
b. During interview have you noted any speech problems? No ___ Yes ___
Describe __________________________________________________________________________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No ___ Yes ___
Describe ___________________________________________________________________________
b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse?
No ___ Yes ___ Describe ______________________________________________________________
c. If the patient is a child, is there evidence of attachment behaviors between the parents and child?
Yes ___ No ___ Describe _____________________________________________________________
d. Any signs or symptoms of alcoholism? No ___ Yes ___ Describe_______________________________
Sexuality-Reproductive Pattern
SUBJECTIVE
Female
1. Date of LMP __________ ; Any pregnancies? Para _____ Gravida _____
Menopause? No ___ Yes ___ Year _______
2. Use birth control measures? No ___ N/A ___ Yes ___ Type ______________________________________
3. Any history of vaginal discharge, bleeding, lesions? No ___ Yes ___
Description ____________________________________________________________________________
4. Pap smear annually? Yes ___ No ___ Date of last pap smear __________
5. Date of last mammogram ___________________
6. History of STD (sexually transmitted disease)? No ___ Yes ___ Describe ___________________________
_____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
APPENDIX B 705
If admission secondary to rape:
7. Is the patient describing numerous physical symptoms? No ___ Yes ___
Describe ____________________________________________________________________________
8. Is the patient exhibiting numerous emotional reactions? No ___ Yes ___ Describe __________________
____________________________________________________________________________________
9. What has been your primary coping mechanism to handle this rape episode? _____________________
____________________________________________________________________________________
10. Have you talked to persons from the rape crisis center? Yes ___ No ___
If no, want you to contact them for her? No ___ Yes ___
If yes, was this contact of assistance? No ___ Yes ___
Male
1. Any history of prostate problems? No ___ Yes ___ Describe ___________________________________
____________________________________________________________________________________
2. Any history of penile discharge, bleeding, lesions? No ___ Yes ___ Describe ______________________
____________________________________________________________________________________
3. Date of last prostate exam _______________________
4. History of STD (sexually transmitted disease)? No ___ Yes ___ Describe _________________________
____________________________________________________________________________________
Both
1. Are you experiencing any problems in sexual functioning? No ___ Yes ___
Describe ____________________________________________________________________________
2. Are you satised with your sexual relationship? Yes ___ No ___ Describe ________________________
____________________________________________________________________________________
3. Do you believe this admission will have any impact on sexual functioning? No ___ Yes ___
Describe ____________________________________________________________________________
OBJECTIVE
Review admission physical exam for results of pelvic and rectal exams. If results not documented, nurse should
perform exams. Check history to see whether admission resulted from a rape.
1. Have you experienced any stressful or traumatic events in the past year in addition to this admission?
No ___ Yes ___ Describe _______________________________________________________________
____________________________________________________________________________________
2. How would you rate your usual handling of stress? Good ____ Average ____ Poor ____
3. What is the primary way you deal with stress or problems? ____________________________________
____________________________________________________________________________________
4. Have you or your family used any support or counseling groups in the past year?
No ___ Yes ___ Group Name ___________________________________________________________
Was support group helpful? Yes ___ No ___ Additional comments _____________________________
____________________________________________________________________________________
5. What do you believe is the primary reason behind the need for this admission?
____________________________________________________________________________________
6. How soon, after rst noting symptoms, did you seek health care assistance?
____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
706 APPENDIX B
7. Are you satised with the care you have been receiving at home? Yes ___ No ___
Comments ___________________________________________________________________________
_____________________________________________________________________________________
8. Ask primary caregiver: What is your understanding of the care that will be needed when the patient goes
home? _______________________________________________________________________________
_____________________________________________________________________________________
OBJECTIVE
1. Observe behavior. Are there any overt signs of stress (e.g., crying, wringing of hands, clenched sts, etc.)?
Describe _____________________________________________________________________________
2. Ask the family or primary caregiver if the patient has threatened to kill himself or herself.
No ___ Yes ___
3. Ask the family or primary caregiver if they have noticed any marked changes in the patients behavior,
attitude, or school performance? No ___ Yes ___
Value-Belief Pattern
SUBJECTIVE
1. Satised with the way your life has been developing? Yes ___ No ___
Comments ___________________________________________________________________________
2. Will this admission interfere with your plans for the future? No ___ Yes ___
How? _______________________________________________________________________________
3. Religion: Protestant ____ Catholic ____ Jewish ____ Islam ____ Buddhist ____
Other _______________________________________________________________________________
4. Will this admission interfere with your spiritual or religious practices? No ___ Yes ___
How? ________________________________________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? No ___ Yes ___
Describe _____________________________________________________________________________
6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you?
No ___ Yes ___ Who? __________________________________________________________________
7. Have your religious beliefs helped you deal with problems in the past? No ___ Yes ___
Comments ____________________________________________________________________________
OBJECTIVE
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying,
withdrawal, etc.)? No ___ Yes ___ Describe__________________________________________________
General
1. Is there any information we need to have that I have not covered in this interview?
No ___ Yes ___ Comments ______________________________________________________________
2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency?
No ___ Yes ___ Questions _______________________________________________________________
_____________________________________________________________________________________
3. What is the rst problem you would like to have assistance with? _________________________________
_____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
APPENDIX B 707
Demographic Data
Vital Signs
708 APPENDIX B
Blood Pressure: Left arm 98/60 ; Right arm 100/64 ; Sitting X Standing ___ Lying down ___
Weight: 230 pounds, ______ kilograms; Height: 5 feet 9 inches, ____ meters
Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here:
APPENDIX B 709
14. Did you think this prescribed routine was the best for you? Yes ____ No X
What would be better? I EAT WHAT I WANT.
15. Have you had any accidents/injuries/falls in the past year? No ____ Yes X
Describe I HIT MY LEG ON THE TABLE A FEW WEEKS AGO.
16. Have you had any problems with cuts healing? No ____ Yes X Describe THIS SORE HAS BEEN HERE
SINCE I HIT IT 3 WEEKS AGO (POINTS TO LT SHIN). THESE SCARS ARE FROM SORES THAT
TOOK AGES TO HEAL (POINTS TO RT LEG).
17. Do you exercise on a regular basis? No X Yes ___ Type and Frequency I USED TO WALK EVERY
AFTERNOON, BUT SINCE I HAVE TO PEE SO MUCH I CANT LEAVE THE HOUSE.
18. Have you experienced any ringing in the ears? Right: Yes ____ No X
Left: Yes ____ No X
19. Have you experienced any vertigo? Yes ____ No X How often and when? _______________________
____________________________________________________________________________________
20. Do you regularly use seat belts? Yes ____ No X
21. For infants and children, are car seats used regularly? Yes ____ No ____
22. Do you have any suggestions or assistance requests for improving your health? No ____ Yes X
What? I WANT TO STOP PEEING SO MUCH.
23. Do you do (breast/testicular) self-examination? No X Yes ____
How often? __________________________________________________________________________
24. Were you or your family able to meet all your therapeutic needs? Yes X No ____
25. Are you scheduled for surgery? Yes ____ No X
26. Have you recently had surgery? No X Yes ____ Date__________
OBJECTIVE
b. Sensorium
Alert ___ ; Drowsy X ; Lethargic ___ ; Stuporous ___ ; Comatose ___ ; Cooperative X ;
c. Memory
Recent? Yes X No ___ ; Remote? Yes X No ___ ; Past 4 hours? Yes ____ No ____
Description of abnormalities___________________________________________
c. Pupil Reaction: Right: Normal X Abnormal ___ ; Left: Normal X Abnormal ____
710 APPENDIX B
4. Taste
a. Sweet: Normal ____ Abnormal ____ Describe NOT EXAMINED
b. Sour: Normal ____ Abnormal ____ Describe NOT EXAMINED
c. Tongue Movement: Normal X Abnormal ____ Describe MIDLINE
d. Tongue Appearance: Normal X Abnormal ____ Describe PINK, NO LESIONS OR EXUDATE
5. Touch
a. Blunt: Normal X Abnormal ____ Describe RESPONDS TO TOUCH ON ALL EXTREMITIES WITH
FLAT TONGUE DEPRESSOR
b. Sharp: Normal ____ Abnormal X Describe DIMINISHED RESPONSE ON LT FOOT
c. Light Touch Sensation: Normal ____ Abnormal X Describe HYPERESTHESIA LT ANKLE AND
RT LEG
d. Proprioception: Normal X Abnormal ____ Describe _____________________________________
e. Heat: Normal ____ Abnormal X Describe DIMINISHED RESPONSE LT FOOT
f. Cold: Normal ____ Abnormal X Describe DIMINISHED RESPONSE LT FOOT
g. Any numbness? No ____ Yes X Describe BILATERALLY IN FEET WHEN WALKING
h. Any tingling? No ____ Yes X Describe PINS AND NEEDLES IN FEET WHEN WALKING
6. Smell
a. Right Nostril: Normal X Abnormal ____ Describe _______________________________________
b. Left Nostril: Normal X Abnormal ____ Describe ________________________________________
7. Assess Cranial Nerves: Normal X Abnormal ____
Describe deviations ____________________________________________________________________
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.): Normal __ Abnormal X
Describe ROMBERG ABSENT, BALANCE GOOD, DOES NOT BEAR FULL WEIGHT ON LT FOOT
Nutritional-Metabolic Pattern
SUBJECTIVE
1. Any weight gain in last 6 months? No ____ Yes X Amount 20 LBS IN LAST 6 WEEKS
2. Any weight loss in last 6 months? No X Yes ____ Amount ___________________________________
3. Would you describe your appetite as: Good X Fair ____ Poor ____
4. Do you have any food intolerances? No X Yes ____ Describe ________________________________
____________________________________________________________________________________
5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as
those that patient restricts voluntarily; for example, to prevent atus.)
No ____ Yes X What SPECIAL DIET MY WIFE FIXES ME FOR DIABETES.
Copyright 2002 F.A. Davis Company
APPENDIX B 711
6. Describe an average days food intake for you (meals and snacks).
BREAKFAST: 3 PANCAKES WITH LOW SUGAR SYRUP, JUICE, BLACK COFFEE, SAUSAGE; LUNCH:
SANDWICH, MILK OR SUGAR-FREE SOFT DRINK, POTATO CHIPS, FRUIT, SOMETIMES A LITTLE
CAKE OR PIE; DINNER: CASSEROLE, ICED TEA, ROLLS WITH BUTTER, VEGETABLES AND
DESSERT (SURE DO LIKE MY ICE CREAM). SNACKS: COOKIES AND JUICE.
7. Describe an average days uid intake for you. I DRINK ALL THE TIME, AT LEAST 4 LARGE GLASSES
PER HOUR.
8. Describe food likes and dislikes LIKES: MEAT, DESSERTS, AND POTATOES; DISLIKES: VEGETABLES
AND LOW SUGAR STUFF
9. Would you like to: Gain weight ____ Lose weight X Neither ____
10. Any problems with:
a. Nausea? No X Yes ____ Describe ____________________________________________________
b. Vomiting? No X Yes ____ Describe __________________________________________________
c. Swallowing? No X Yes ____ Describe ________________________________________________
d. Chewing? No X Yes ____ Describe __________________________________________________
e. Indigestion? No X Yes ____ Describe _________________________________________________
11. Would you describe your usual lifestyle as: Active ___ Sedate X
12. Any chronic health problems? No ____ Yes X Describe DIABETES MELLITUS
OBJECTIVE
1. Skin Examination
a. Warm ___ Cool X Moist ___ Dry X
b. Lesions? No ____ Yes X Describe 10 CM LT SHIN SEVERAL CM DEEP; RED 3 ROUND SCARS
WITH ATROPHIED SKIN ON RT LEG; 1 ON LT LEG.
c. Rash? No X Yes ____ Describe ______________________________________________________
d. Turgor: Firm ____ Supple ____ Dehydrated X Fragile ____
e. Color: Pale ____ ; Pink ____ ; Dusky ____ ; Cyanotic ____ ; Jaundiced ____ ; Mottled ____ ;
Other PINK EXCEPT FOR LEGS. LEGS ARE CYANOTIC IN DEPENDENT POSITION; PALE WHEN
ELEVATED.
2. Mucous Membranes
a. Mouth
(1) Moist ___ Dry X
(2) Lesions? No X Yes ____ Describe_________________________________________________
(3) Color: Pale X Pink ____
(4) Teeth: Normal X Abnormal ____ Describe _________________________________________
(5) Dentures? No ____ Yes ____ Upper ____ Lower ____ Partial X
(6) Gums: Normal X Abnormal ____ Describe _________________________________________
(7) Tongue: Normal X Abnormal ____ Describe ________________________________________
b. Eyes
(1) Moist ____ Dry X
(2) Color of conjunctivae: Pale ____ Pink X Jaundiced ____
(3) Lesions? No X Yes ____ Describe _________________________________________________
3. Edema
a. General? No X Yes ____ Describe ____________________________________________________
_________________________________________________________________________________
Abdominal Girth: _______inches; Not measured X
Copyright 2002 F.A. Davis Company
712 APPENDIX B
Elimination Pattern
SUBJECTIVE
1. What is your usual frequency of bowel movements? ABOUT 3 TIMES PER WEEK
a. Have to strain to have BM? No X Yes ____
b. Same time each day? No X Yes ____
2. Has the number of bowel movements changed in the past week? No X Yes ____
Increased ____ Decreased ____
3. Character of stool:
a. Consistency: Hard ____ Soft X Liquid ____
b. Color: Brown X Black ____ Yellow ____ Clay colored ____
c. Bleeding with bowel movements? No X Yes ____
4. History of constipation? No X Yes ____ How often ________________________________________
Use bowel movement aids (laxatives, suppositories, diet)? No X Yes ____
Describe ____________________________________________________________________________
5. History of diarrhea? No X Yes ____ When ________________________________________________
6. History of incontinence? No X Yes ____
Related to increased abdominal pressure (coughing, laughing, sneezing)? No ___Yes ___
7. History of recent travel? No X Yes ____Where? ____________________________________________
8. Usual voiding pattern:
a. Frequency (times/day) FOR PAST 3 DAYS, 34/HOUR
Decreased ___ Increased X
b. Change in awareness of need to void? No ____ Yes X
Increased ____ Decreased X
c. Change in urge to void? No ____ Yes X Increased X Decreased ____
d. Any change in amount? No ____ Yes X Decreased ____ Increased X
e. Color: Yellow VERY PALE Smoky ____ Dark ____
f. Incontinence? No ____ Yes X When IF TOO FAR FROM BATHROOM.
Difculty holding voiding when urge to void develops? No ____ Yes X
Have time to get to bathroom? Yes ____ No X
How often does problem reaching bathroom occur? EVERY VOIDING
g. Retention? No X Yes ____ Describe ___________________________________________________
h. Pain or burning? No X Yes ____ Describe ______________________________________________
i. Sensation of bladder spasms? No X Yes ____ When? _____________________________________
Copyright 2002 F.A. Davis Company
APPENDIX B 713
OBJECTIVE
1. Auscultate abdomen.
a. Bowel Sounds: Normal X Increased ____ Decreased ____ Absent ____
2. Palpate abdomen.
a. Tender? No X Yes ____ Where? ______________________________________________________
b. Soft? Yes X No ____; Firm? Yes ____ No X
c. Masses? No X Yes ____ Describe _____________________________________________________
d. Distention (include distended bladder)? No X Yes ____ Describe ____________________________
__________________________________________________________________________________
e. Overow urine when bladder palpated? Yes ____ No X
3. Rectal Exam
a. Sphincter tone: Describe WITHIN NORMAL LIMITS
b. Hemorrhoids? No X Yes ____ Describe ________________________________________________
c. Stool in rectum? No ____ Yes X Describe HEME NEGATIVE
d. Impaction? No X Yes ____ Describe ___________________________________________________
e. Occult blood? No X Yes ____
4. Ostomy present? No X Yes ____ Location _________________________________________________
Activity-Exercise Pattern
SUBJECTIVE
1. Using the following Functional Level Classication, have the patient rate each area of self-care. (Code
adapted by NANDA from Jones, E, et al: Patient Classication for Long-Term Care: Users Manual, HEW
Publication No. HRA-74-3107. November, 1974.)
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person, for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependent, does not participate in activity
Feeding 0 ; Bathing-hygiene 0 ; Dressing-grooming 0 ;
714 APPENDIX B
OBJECTIVE
1. Cardiovascular
a. Cyanosis? No ____ Yes X Where? LEGS WHEN DEPENDENT
b. Pulses: Easily palpable?
Carotid: Yes X No ___; Jugular: Yes X No ___; Temporal: Yes X No ___;
Radial: Yes X No ___; Femoral: Yes X No ___; Popliteal: Yes X No ___;
Post tibial: Yes___ No X ; Dorsalis pedis: Yes___ No X
c. Extremities:
(1) Temperature: Cold ____ Cool X Warm ____ Hot ____
(2) Capillary Rell: Normal ____ Delayed X
(3) Color: Pink ____ Pale X Cyanotic X Other ____
Describe: PALE WHEN RAISED; CYANOTIC WHEN DEPENDENT
(4) Homans sign? No X Yes ____
(5) Nails: Normal ____ Abnormal X Describe TOENAILS AND FINGERNAILS DRY, THICK,
BRITTLE
(6) Hair Distribution: Normal X Abnormal ____ Describe ________________________________
____________________________________________________________
(7) Claudication? No ____ Yes X Describe NUMBNESS AND TINGLING IN FEET
d. Heart: PMI Location 4TH ICS LCL
(1) Abnormal rhythm? No X Yes ____ Describe ________________________________________
______________________________________________________________________________
(2) Abnormal sounds? No X Yes ____ Describe ________________________________________
______________________________________________________________________________
2. Respiratory
a. Rate 20/MIN ; Depth: Shallow ____ Deep X Abdominal ____ Diaphragmatic X
b. Have the patient cough. Any sputum? No X Yes ____ Describe _____________________________
_________________________________________________________________________________
c. Fremitus? No X Yes ____
d. Any chest excursion? No X Yes ____ Equal ____ Unequal ____
e. Auscultate chest:
Any abnormal sounds (rales, rhonchi)? No X Yes ____
Describe __________________________________________________________________________
f. Have the patient walk in place for 3 minutes (if permissible):
(1) Any shortness of breath after activity? No X Yes ____
(2) Any dyspnea? No X Yes ____
(3) BP after activity 108 / 74 in (right; left) arm
(4) Respiratory rate after activity 25
(5) Pulse rate after activity 110
3. Musculoskeletal
a. Range of motion: Normal ____ Limited X Describe LIMITED IN LOWER EXTREMITIES
Copyright 2002 F.A. Davis Company
APPENDIX B 715
b. Gait: Normal ____ Abnormal X Describe DOES NOT BEAR FULL WEIGHT ON LEFT ANKLE
c. Balance: Normal X Abnormal ____ Describe ___________________________________________
d. Muscle Mass/Strength: Normal ____ Increased ____ Decreased X
Describe ATROPHY IN BOTH LEGS, ESPECIALLY IN AREA OF WOUNDS
e. Hand Grasp: Right: Normal X Decreased ____
Left: Normal X Decreased ____
f. Toe Wiggle: Right: Normal X Decreased ____
Left: Normal X Decreased ____
g. Posture: Normal X Kyphosis ____ Lordosis ____
h. Deformities? No X Yes ____ Describe _________________________________________________
i. Missing limbs? No X Yes ____ Where? ________________________________________________
j. Uses mobility assistive devices (walker, crutches, etc.)? No X Yes ____
Describe _________________________________________________________________________
k. Tremors? No X Yes ____ Describe ____________________________________________________
l. Traction or casts present? No X Yes ____ Describe _______________________________________
m. Easily turns in bed? No ____ Yes X
4. Spinal cord injury? No X Yes ____ Level ________________________________________________
5. Paralysis present? No X Yes ____ Where? ________________________________________________
6. Conduct developmental assessment. Normal ____ Abnormal ____ Describe NOT DONE
___________________________________________________________________________________
7. Responds appropriately to stimuli? Yes X No ____ Describe _________________________________
___________________________________________________________________________________
8. Are there any abnormal movements? No X Yes ____ Describe _______________________________
___________________________________________________________________________________
9. Frequent locomotion? Yes ____ No X
10. Episodes of trespassing or getting lost? Yes ____ No X
Sleep-Rest Pattern
SUBJECTIVE
1. Usual sleep habits: Hours/night 6 ; Naps? No ___ Yes X a.m. ___ p.m. X
Feel rested? Yes X No ____ Describe ___________________________________________________
2. Any problems:
a. Difculty going to sleep? No X Yes____
b. Awakening during night? No ____ Yes X (TO GO TO THE BATHROOM)
c. Early awakening? No X Yes____
d. Insomnia? No X Yes ____ Describe __________________________________________________
3. Methods used to promote sleep: Medication? No X Yes ____ Name ___________________________
Warm uids? No X Yes ____ What? ____________________________________________________
Relaxation techniques? No X Yes ____
OBJECTIVE
None
Copyright 2002 F.A. Davis Company
716 APPENDIX B
Cognitive-Perceptual Pattern
SUBJECTIVE
1. Pain
a. Location (have the patient point to area ) LEFT SHIN
b. Intensity (have the patient rank on scale of 010) 5
c. Radiation? No ____ Yes X To where UP LEG
d. Timing (how often; related to any specic events) ACHES ALL THE TIME; INCREASED PAIN WITH
WALKING OR IF TOUCH WOUND.
e. Duration AS ABOVE
f. What do you do to relieve pain at home? ELEVATE, TAKE AN ADVIL
g. When did pain begin? TWO WEEKS AGO
2. Decision Making
a. Find decision making: Easy X Moderately easy ____ Moderately difcult ____ Difcult ____
b. Inclined to make decisions: Rapidly X Slowly ____ Delay ____
c. Difculty choosing between options? Yes ____ No X Describe ______________________________
__________________________________________________________________________________
3. Knowledge level
a. Can dene what current problem is? Yes X No ____
b. Can restate current therapeutic regimen? Yes X No ____
OBJECTIVE
1. Review sensory and mental status completed in Health PerceptionHealth Management Pattern.
2. Any overt signs of pain? No ____Yes X Describe WINCES WHEN TRIES TO BEAR WEIGHT ON LEFT
LEG
3. Any uctuations in intercranial pressure? Yes ____ No X
1. What is your major concern at the current time? IM TIRED OF DOING NOTHING BUT DRINKING
AND PEEING.
2. Do you think this admission will cause any lifestyle changes for you? No ___ Yes X
What? HELP ME GET BETTER.
3. Do you think this admission will result in any body changes for you? No ___ Yes X
What? HEAL MY LEG.
4. My usual view of myself is: Positive X Neutral ___ Somewhat negative ___
5. Do you believe you will have any problems dealing with your current health situation? No X Yes ___
Describe _____________________________________________________________________________
6. On a scale of 05, rank your perception of your level of control in this situation 4
7. On a scale of 05, rank your usual assertiveness level 5
8. Have you recently experienced a loss? No X Yes ___ Describe _________________________________
_____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
APPENDIX B 717
OBJECTIVE
1. During assessment, the patient appears: Calm ____ Anxious ____ Irritable X
Role-Relationship Pattern
SUBJECTIVE
1. Does the patient live alone? Yes ____ No X Lives with: WIFE
2. Is the patient married? Yes X No ___; Children? No X Yes ____; # of children___
Age(s) of children__________________________
Were any of the children premature? No ____ Yes ____ Describe N/A
____________________________________________________________________________________
3. How would you rate your parenting skills: Not applicable X
No difculty with ____ Average ____ Some difculty with ____ Describe ________________________
____________________________________________________________________________________
4. Any losses (physical, psychological, social) in past year? No ____ Yes X
5. How is the patient handling this loss at this time? DOING FINE, JUST NEED TO GET FEET IN SHAPE
SO I CAN DO WHAT I WANT NOW THAT I HAVE THE TIME.
6. Do you believe this admission will result in any type of loss? No X Yes ____
Describe ____________________________________________________________________________
7. Has the patient recently received a diagnosis related to a chronic physical or mental illness?
No X Yes____
718 APPENDIX B
OBJECTIVE
1. Speech Pattern
a. Is English the patients native language? Yes X No ____
Native language is______________; Interpreter needed? No X Yes ____
b. During interview have you noted any speech problems? No X Yes ____
Describe __________________________________________________________________________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No X Yes ____
Describe _________________________________________________________________________
b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse?
No ____ Yes ____ Describe __________________________________________________________
_________________________________________________________________________________
c. If the patient is a child, is there evidence of attachment behaviors between the parents and child?
Yes ____ No ____ Describe N/A
d. Any signs or symptoms of alcoholism? No X Yes ____ Describe ____________________________
_________________________________________________________________________________
Sexuality-Reproductive Pattern
SUBJECTIVE
Female
1. Date of LMP__________; Any pregnancies? Para_____ Gravida_____
Menopause? No ____ Yes ____ Year_______
2. Use birth control measures? No____ N/A ____ Yes ____ Type _________________________________
3. Any history of vaginal discharge, bleeding, lesions? No ____ Yes ____
Describe ___________________________________________________________________________
4. Pap smear annually? Yes ____ No ____ Date of last pap smear__________
5. Date of last mammogram_________
6. History of STD (sexually transmitted disease)? No ____ Yes ____ Describe _______________________
____________________________________________________________________________________
Male
1. Any history of prostate problems? No X Yes ____ Describe __________________________________
____________________________________________________________________________________
2. Any history of penile discharge, bleeding, lesions? No X Yes ____ Describe _____________________
____________________________________________________________________________________
3. Date of last prostate exam? LAST ADMISSION
4. History of STD (sexually transmitted disease)? No X Yes ____ Describe ________________________
____________________________________________________________________________________
Copyright 2002 F.A. Davis Company
APPENDIX B 719
Both
1. Are you experiencing any problems in sexual functioning? No ____ Yes X
Describe IMPOTENCY FOR PAST SEVERAL MONTHS
2. Are you satised with your sexual relationship? Yes ____ No X
Describe IMPOTENT
3. Do you believe this admission will have any impact on sexual functioning? No ____Yes X
OBJECTIVE
Review admission physical exam for results of pelvic and rectal exams. If results not documented, nurse should
perform exams. Check history to see whether admission resulted from a rape.
1. Have you experienced any stressful or traumatic events in the past year in addition to this admission?
No ____ Yes X Describe NUMEROUS ADMISSIONS AND I MISS WORK SOME
2. How would you rate your usual handling of stress: Good ____Average X Poor ____
3. What is the primary way you deal with stress or problems? YELL OR AVOID SITUATION. I DONT LIKE
TO TALK ABOUT IT.
4. Have you or your family used any support or counseling groups in the past year?
No X Yes ____ Group Name ___________________________________________________________
Was support group helpful? Yes ____ No ____ Additional comments ____________________________
_____________________________________________________________________________________
5. What do you believe is the primary reason behind the need for this admission? TO GET MY DIABETES
UNDER CONTROL AGAIN; I GUESS IM A SLOW LEARNER.
6. How soon, after rst noting symptoms, did you seek health care assistance? 3 WEEKS
7. Are you satised with the care you have been receiving at home? Yes X No ____
Comments MY WIFE HAS ALWAYS TAKEN GOOD CARE OF ME AND I DIDNT WANT TO HAVE
THOSE PEOPLE (V.N.A.) COMING TO MY HOUSE.
8. Ask primary caregiver: What is your understanding of the care that will be needed when the patient goes
home? WIFE NOT PRESENT AT THIS TIME
_____________________________________________________________________________________
OBJECTIVE
1. Observe behavior. Are there any overt signs of stress (e.g., crying, wringing of hands, clenched sts, etc.)?
Describe CLENCHED FISTS
_____________________________________________________________________________________
2. Has the patient threatened to kill himself or herself? Yes ____ No X
3. Ask the family: Has the patient demonstrated any marked changes in behavior, attitude or school
performance? Yes ____ No X
Copyright 2002 F.A. Davis Company
720 APPENDIX B
Value-Belief Pattern
SUBJECTIVE
1. Are you satised with the way your life has been developing? Yes ____ No X
Comments WAS O.K. UNTIL THIS DIABETES DEVELOPED.
2. Will this admission interfere with your plans for the future? No X Yes ____
How? _______________________________________________________________________________
3. Religion: Protestant X Catholic ____ Jewish ____ Islam ____ Buddhist ____
4. Will this admission interfere with your spiritual or religious practices? No X Yes ____
How? _______________________________________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? NO
6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you?
No X Yes ____ Which? _______________________________________________________________
7. Have your religious beliefs helped you to deal with problems in the past? No __Yes X
Comments NONE
OBJECTIVE
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying,
withdrawal, etc.)? No ____ Yes X What CLENCHED FISTS
General
1. Is there any information we need to have that I have not covered in this interview?
No X Yes ____ Comments _____________________________________________________________
2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency?
No X Yes ____ Questions _____________________________________________________________
_____________________________________________________________________________________
3. What is the rst problem you would like to have assistance with? STOP ME FROM HAVING TO GO TO
THE BATHROOM ALL THE TIME
Copyright 2002 F.A. Davis Company
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Nurs Res 4:122, 1991. 3:69, 1989.
20. Kemp, C: Terminal Illness: A Guide to Nursing Care, ed 2. Lippincott, 30. Burkhardt, MA: Becoming and connecting: Elements of spirituality for
Williams & Wilkins, Philadelphia, 1999. women. Holist Nurs Pract 8:12, 1994.
Copyright 2002 F.A. Davis Company
INDEX
Page numbers followed by t indicate tables. Page numbers followed by f indicate gures.
Activity-exercise pattern
NANDA taxonomy, Nursing Interventions
nutritional-metabolic pattern, 9091
Activity-exercise pattern
Classication, Nursing Outcomes
proprioception, 384
developmental considerations
womens health, 233235
visual development, 384
adolescents, 229
related factors, 231
Adult failure to thrive
adults, 230
risk for, 231
characteristics of, 92
infants, 226227
Adaptive capacity, intracranial, decreased
clinical concerns, 92
preschoolers, 227228
clinical concerns, 385
differential diagnosis, 92
toddlers, 227228
differential diagnosis, 386
NANDA taxonomy, Nursing Interventions
301307
Classication, 385
nursing actions/interventions
response, 280284
expected outcome, 386, 390
gerontic health, 94
fatigue, 289293
gerontic health, 389
psychiatric health, 9394
301307
target dates, 386
related factors, 92
for, 318321
characteristics of, 637
copingstress tolerance pattern, 636
337340
caregiver role strain, 527
hearing development, 385
wandering, 360363
Classication, 637
older. See Older adults
Activity intolerance
adult health, 638
role-relationship pattern, 525
actual, 231
child health, 638
self-perception/self-concept pattern, 456
733
Copyright 2002 F.A. Davis Company
734 INDEX
Airway clearanceContinued
Apgar score, 383
owchart evaluation, 255
Classication, 239
Classication, Nursing Outcomes
Belief pattern. See Value-belief pattern
nursing actions/interventions
Classication, 97
Birthing process. See Childbirth
response
data sources and types, 3
NANDA taxonomy, Nursing
Anxiety
Auditory decit, nursing
nursing actions/interventions
developmental considerations
clinical concerns, 246
home health, 469
adolescents, 455
denition of, 246
psychiatric health, 468469
infants, 453454
differential diagnosis, 247
target dates, 465
constipation, 200
adult health, 247248
Body system approach, to patient
death anxiety, 471
child health, 248
assessment, 34
decisional conict, 400
expected outcome, 247, 250
Body temperature, imbalanced, risk for
diarrhea, 206
owchart evaluation, 250
characteristics of, 102
fear, 476
gerontic health, 248
clinical concerns, 102
grieving
home health, 249
denition of, 102
anticipatory, 544
psychiatric health, 248
differential diagnosis, 102
dysfunctional, 551
target dates, 247
hyperthermia, 140
hopelessness, 484
womens health, 248
hypothermia, 145
powerlessness, 501
Autonomy, 62, 227, 612
NANDA taxonomy, Nursing Interventions
Classication, 456
Bathing, toddlers and preschoolers, 227
adult health, 102103
nursing actions/interventions
Bathing-hygiene self-care decit, 330
child health, 103104
INDEX 735
Bowel incontinence
adult health, 115
school-age children, 228229
constipation, 200
psychiatric health, 117
tissue perfusion. See Tissue perfusion,
Classication, 195
pain, 415416
valuation of, 1314
nursing actions/interventions
Breathing pattern, ineffective
Caregiver. See also Parent to your parents;
adult health, 196
characteristics of, 256
Parental role
child health, 196
clinical concerns, 256
resources for, 530
Breast milk, 89
Classication, 256
Classication, 526
Breastfeeding
nursing actions/interventions
nursing actions/interventions
effective
child health, 257258
child health, 528
Interventions Classication,
psychiatric health, 259
psychiatric health, 530531
107
womens health, 258
womens health, 528529
nursing actions/interventions
related factors, 256
related factors, 526527
expected outcome, 107, 109
Brown adipose tissue, 90
risk for, 526
150
uid volume, excess, 129
Circadian rhythm, 367
nursing actions/interventions
Interventions Classication,
adaptive capacity, intracranial, decreased,
adult health, 111
Nursing Outcomes Classication,
385390
interrupted
psychiatric health, 266267
infants, 382383
736 INDEX
Cognitive-perceptual patternContinued
NANDA taxonomy, Nursing Interventions
owchart evaluation, 475
pain, 421430
nursing actions/interventions
psychiatric health, 473
Colic, 194
gerontic health, 204
clinical concerns, 400
Collaborative action, 6
home health, 204
denition of, 400
communication, impaired
womens health, 203204
Classication, Nursing Outcomes
Community coping
perceived, 199200
Classication, 400
ineffective, 645646
Convection, loss of body heat, 89
gerontic health, 403
Classication, 645
defensive, 661
target dates, 400
nursing actions/interventions
denition of, 633634
womens health, 401
Compliance, 62
adolescents, 635636
Classication, 301
role conict
preschoolers, 635
child health, 302303
Confusion
school-age children, 635
expected outcome, 302, 307
acute, 391
toddlers, 635
gerontic health, 305
chronic, 391
family coping
psychiatric health, 303304
impaired, 406
post-trauma syndrome, 670675
444
Classication, 391
Cues to action, 16, 17f
443444
nursing actions/interventions
Current data, 3
Denial, ineffective, 661
Constipation
clinical concerns, 471
NANDA taxonomy, Nursing Interventions
diarrhea, 206
child health, 472
child health, 120
INDEX 737
adults, 91
womens health, 271
bowel incontinence, 195198
development, delayed
Diversional activity, decient
constipation, 199205
denition of, 4
clinical concerns, 275
developmental considerations
nursing, 4
denition of, 275279
adolescents, 194
statements, 45
differential diagnosis, 275
adults, 194
Diarrhea
NANDA taxonomy, Nursing Interventions
infants, 193194
constipation, 200
expected outcome, 275, 279
diarrhea, 206210
requirements, 157
home health, 278
Enactive mode, in Piagets theory of
NANDA taxonomy, Nursing Interventions
psychiatric health, 277278
cognitive development, 382
Classication, 206
womens health, 276277
Energy eld disturbance
nursing actions/interventions
related factors, 275
characteristics of, 21
Classication, 301
characteristics of, 280
differential diagnosis, 406
nursing actions/interventions
clinical concerns, 280
NANDA taxonomy, Nursing Interventions
Classication, 270
dysreexia
data collection, 9
738 INDEX
As evidenced by, 4
psychiatric health, 652654
differential diagnosis, 535
Expected outcome, 5
related factors, 650
Nursing Outcomes Classication,
240t
characteristics of, 650
nursing actions/interventions
Exteroceptor, 382
denition of, 650
child health, 536
Extracellular uid, 88
differential diagnosis, 651
expected outcome, 535, 543
enhanced, 657
home health, 541542
Failure to thrive
alcoholism, 535
target dates, 535
infant, 454
health maintenance, ineffective, 27
related factors, 535
Faith, 681682. See also Value-belief pattern home maintenance, impaired, 308
interrupted
Classication, 285
Outcomes Classication, 650
308
nursing actions/interventions
nursing actions/interventions
parent, infant, and child attachment,
Family
readiness for enhanced
adult health, 535536
compromised
family coping, compromised, 651
home health, 541542
enhanced, 657
657
Fatigue
alcoholism, 535
adult health, 657
clinical concerns, 289
management of, 62
target dates, 657
muscular, 226
Interventions Classication,
Family in later life, 636
Classication, 289
650
Family processes
adult health, 289290
nursing actions/interventions
dysfunctional, differential diagnosis,
child health, 290
INDEX 739
Fear
characteristics of, 129
expected outcome, 294, 300
developmental considerations
adaptive capacity, intracranial, psychiatric health, 297298
adolescents, 455
decreased, 386
target dates, 294
adults, 456
diarrhea, 206
womens health, 297
infants, 453454
uid volume, imbalanced, risk for,
related factors, 294
anxiety, 457
Interventions Classication,
tissue perfusion. See Tissue perfusion,
grieving
Nursing Outcomes Classication,
ineffective
anticipatory, 544
129
Gender identity, 611613
dysfunctional, 551
nursing actions/interventions
Gender orientation, 613
hopelessness, 484
adult health, 130
Gender preference, 613
requirements, 157
expected outcome, 129, 135
General-adaptation syndrome (GAS),
Classication, 476
home health, 133134
634635
nursing actions/interventions
psychiatric health, 132133
macrosociocultural, 635
Feces, 192
nursing actions/interventions
sorrow, chronic, 591
Flatulence, 193
psychiatric health, 138
child health, 544545
Fluid volume
target dates, 136
expected outcome, 544, 550
denition of, 88
womens health, 138
owchart evaluation, 550
decient
risk factors, 136
gerontic health, 548549
actual, 123
FOCUS charting, 8
home health, 549
constipation, 200
Functional residual capacity, denition of,
clinical concerns, 551
diarrhea, 206
240t
denition of, 551
136
adjustment, impaired, 637
Interventions Classication,
characteristics of, 294
nutrition, imbalanced, less than body
123
denition of, 294
post-trauma syndrome, 671
nursing actions/interventions
differential diagnosis, 294
NANDA taxonomy, Nursing
740 INDEX
GrievingContinued
older adults, 2021
constipation, 204
227228
infection, risk for, 3741 305306
Classication, 301
effective management of, 5760 falls, risk for, 287
nursing actions/interventions
ineffective management of, 6170 family coping
actions/interventions, 424425
child health, 34
imbalanced, risk for, 138
Hallucinations, nursing
gerontic health, 35
anticipatory, 549
actions/interventions, 437,
home health, 35
dysfunctional, 554555
442444
psychiatric health, 3435
growth and development, delayed,
Hardiness, description of, 635
target dates, 33
305306
assessment, 3
Healthy People 2010, 18
health-seeking behaviors, 35
characteristics of, 27
437
hyperthermia, 143
clinical concerns, 27
developmental considerations
hypothermia, 148
denition of, 27
adolescents, 384
individual coping, ineffective, 668
differential diagnosis, 27
adults and older adults, 385
infant behavior, disorganized, 316
nutrition, imbalanced
Heart rate, cardiac output and, 262
infection, risk for, 40
Classication, 27
389
nausea, 155
nursing actions/interventions
adjustment, impaired, 643
nutrition, imbalanced
child health, 29
airway clearance, ineffective, 243244
more than body requirements, 171
owchart evaluation, 32
aspiration, risk for, 100
parent, infant, and child attachment,
gerontic health, 31
autonomic dysreexia, 249
impaired, risk for, 559
home health, 31
bed mobility, impaired, 254
parental role conict, 568
psychiatric health, 30
body image, disturbed, 469
parenting, impaired, 568
target dates, 28
body temperature, imbalanced, risk for,
perioperative-positioning injury, risk for,
related factors, 27
bowel incontinence, 197
peripheral neurovascular dysfunction, risk
pattern
effective, 108
personal identity, disturbed, 499
developmental considerations
cardiac output, decreased, 268
protection, ineffective, 79
adolescents, 20
caregiver role strain, 532
rape-trauma syndrome, 619
adults, 20
community coping, 648
relocation stress syndrome, 572
infants, 1819
confusion, 396397
role performance, ineffective, 578
INDEX 741
enhanced, 691
Human response patterns, 1011, 11t
characteristics of, 661
therapeutic regimen
clinical concerns, 140
activity intolerance, 231
wandering, 362
expected outcome, 140, 144
relocation stress syndrome, 570
health-seeking behaviors, 33
Hypothermia
therapeutic regimen, ineffective
management of, 62
denition of, 145
NANDA taxonomy, Nursing Interventions
Classication, 308
102
nursing actions/interventions
nursing action/interventions
hyperthermia, 140
adult health, 662
developmental considerations
NANDA taxonomy, Nursing
adults, 456
Interventions Classication,
infants, 454
Iconic mode, in Piagets theory of cognitive
Nursing Outcomes Classication,
742 INDEX
InfantsContinued
Infertility, nursing actions/interventions, 485
powerlessness, 501
behavior, 313
perioperative-positioning injury, risk
Classication, 410
nursing actions/interventions
risk factors for
Landau reex, 383
pattern, 1819
Interoceptor, 382
nursing actions/interventions
proprioception, 383
Intravascular uid, 88
home health, 55
self-perception/self-concept pattern,
target dates, 51
453454
womens health, 5455
characteristics of, 37
perfusion, ineffective
Loneliness, risk for
clinical concerns, 37
Kin network, 522
clinical concerns, 491
denition of, 37
Kinesthesia decit, nursing actions/interven-
denition of, 491
differential diagnosis, 37
tions, 433434, 436
differential diagnosis, 492
protection, ineffective, 75
Kinship system, 522
NANDA taxonomy, Nursing Interventions
Classication, 37
characteristics of, 410
adult health, 491492
nursing actions/interventions
clinical concerns, 410
child health, 492
child health, 38
differential diagnosis, 410
owchart evaluation, 496
owchart evaluation, 41
fear, 476
home health, 495
gerontic health, 40
health maintenance, ineffective, 27
psychiatric health, 493495
home health, 40
home maintenance, impaired, 308
target dates, 492
psychiatric health, 39
injury, risk for, 43
womens health, 492493
target dates, 37
nutrition, imbalanced, more than body
risk factors, 491
INDEX 743
resources, 635
gerontic health, 154
diarrhea, 206
Malnutrition, 88
psychiatric health, 154
302
Meconium, 194
related factors, 153
growth and development, delayed,
Memory, impaired
Near miss sudden infant death syndrome
302
confusion, 391
role-relationship pattern, 522523
swallowing, impaired, 174
Classication, 416
Non-rapid eye movement (NREM) sleep,
child health, 160161
nursing actions/interventions
367, 369
expected outcome, 157, 165
pattern
Nursing actions. See also specic nursing
differential diagnosis, 166
226
denition of, 6
physical mobility, impaired, 322
impaired
denition of, 4
166
impaired
care plan
child health, 169
impaired
valuation of, 1314
owchart evaluation, 172
Musculoskeletal system
documentation, 79
target dates, 166
developmental considerations
evaluation, 9
womens health, 170
adolescents, 229
nursing actions, 67
related factors, 166
adults, 230
planning, 56
risk for, 166
infants, 227
conceptual frameworks
Nutritional-metabolic pattern
behavior
owchart, 10f
breastfeeding
planning of care, 23
effective, 107109
purpose of, 1
ineffective, 110114
Narcolepsy, 367
standards of care, 2t
interrupted, 115118
Nausea
Nursing standards, 2, 2t
conceptual information, 87
Classication, 153
denition of, 157
infants, 8990
744 INDEX
Nutritional-metabolic patternContinued
NANDA taxonomy, Nursing Interventions
Parenting, impaired
preschoolers, 90
Classication, 421
characteristics of, 561
school-age children, 90
nursing actions/interventions
clinical concerns, 562
toddlers, 90
adult health, 422423
denition of, 561
young adults, 91
child health, 423424
differential diagnosis, 563
150152
psychiatric health, 426427
uid volume, decient, 123
nausea, 153156
target dates, 421
parent, infant, and child attachment,
nutrition, imbalanced
womens health, 424425
impaired, risk for, 557
family processes
expected outcome, 563, 569
Objective data, 3
dysfunctional: alcoholism, 537
owchart evaluation, 569
Older adults
interrupted, 537
gerontic health, 567
pattern, 2021
NANDA taxonomy, Nursing Interventions
risk for, 561
proprioception, 385
child health, 557558
pattern
role-relationship pattern, 525
expected outcome, 557, 560
alterations in. See Sensory perception,
self-perception/self-concept pattern, 456
owchart evaluation, 560
disturbed
sexuality-reproductive pattern, 613
home health, 559
denition of, 382
actions/interventions, 434
family processes
clinical concerns, 71
differential diagnosis
self-esteem disturbance, 510511 NANDA taxonomy, Nursing Interventions
requirements, 157
clinical concerns, 562
adult health, 7172
Overweight, 88
NANDA taxonomy, Nursing Interventions
owchart evaluation, 74
Classication, 561
home health, 73
Pain
nursing actions/interventions
psychiatric health, 73
acute, 421
adult health, 563
target dates, 71
chronic, 421
expected outcome, 563, 569
related factors, 71
requirements, 157
related factors, 562
for, 71
INDEX 745
Classication, 318
related factors, 322
gerontic health, 505
nursing actions/interventions
Physiology, toddlers and preschoolers,
home health, 505506
Peristalsis, 192
toddlers and preschoolers, 523
weight gain in, 161, 170
anxiety, 457
denition of, 670
activity-exercise pattern, 227228
Classication, 497
nursing actions/interventions
pattern, 19
nursing actions/interventions
adult health, 671
nutritional-metabolic pattern, 90
constipation, 200
depression, 485
documentation system, 8
Classication, 322
hopelessness, 484
Classication, 75
nursing actions/interventions
individual coping, ineffective, 662
nursing actions/interventions
746 INDEX
Protection, ineffectiveContinued
injury, risk for, 47
of toddler/preschooler, 613
target dates, 75
knowledge, decient, 413
of young adult, 613
related factors, 75
loneliness, risk for, 493495
characteristics of, 614
activity intolerance, 235236 less than body requirements, 163164 post-trauma syndrome, 671
389
pain, 426427
male victim, 616
anxiety, 461463
peripheral neurovascular dysfunction, risk
nursing actions/interventions
104105
protection, ineffective, 78
home health, 619
breastfeeding
relocation stress syndrome, 571572
target dates, 614
ineffective, 112
role performance, ineffective, 576577
womens health, 617
interrupted, 117
self-care decit, 333334
related factors, 614
confusion, 393395
sexuality patterns, ineffective, 630631
87
constipation, 204
sleep deprivation, 372
Reex urinary incontinence, 211
impaired, 407408
therapeutic regimen
Classication, Nursing Outcomes
family coping
ineffective management of, 6567
nursing actions/interventions
fatigue, 291292
urinary incontinence, 215216
psychiatric health, 571572
fear, 479481
urinary retention, 221
target dates, 570
uid volume
verbal communication, impaired, 598600
womens health, 571
decient, 127
violence, risk for, 605608
related factors, 570
excess, 132133
walking, impaired, 358
risk for, 570
303304
Respiratory system
hopelessness, 486488
Radiation, loss of body heat, 89
infants, 227
hyperthermia, 142143
Rape
older adults, 230
hypothermia, 147
of adolescent, 613
school-age children, 228229
INDEX 747
ineffective
cognitive-perceptual pattern, 384
Classication, Nursing Outcomes
Restraints, 271
pattern, 1920 child health, 509510
Risk for, 5
nutritional-metabolic pattern, 90
gerontic health, 512
Role
role-relationship pattern, 524
home health, 513
Classication, 574
characteristics of, 330
denition of, 515
nursing actions/interventions
clinical concerns, 330
differential diagnosis, 516
Role-play, 384
dressing-grooming, 330
home health, 517518
Role-relationship pattern
feeding, 330
psychiatric health, 516517
developmental considerations
adult health, 331332
Self-perception, development of, 453
adolescents, 524525
child health, 332
Self-perception/self-concept pattern
preschoolers, 523524
home health, 335
conceptual information, 452453
toddlers, 523524
target dates, 331
description of, 10, 11t, 451
parenting, impaired, 561569 Self-concept pattern. See Self-perception/self- loneliness, risk for, 491496
diarrhea, 206
adjustment, impaired, 637
Salivation, 89
requirements, 157
delayed development, risk for, 302
School-age children
personal identity, disturbed, 497
disproportionate growth, risk for, 302
748 INDEX
grieving
description of, 10, 11t, 611
home health, 379
anticipatory, 544
developmental considerations
psychiatric health, 378
dysfunctional, 551
adolescents, 613
target dates, 376
requirements, 157
preschoolers, 612613
assessment of, 367
596
rape-trauma syndrome, 614620
adolescents, 369
Classication, 431
628632
older adults, 369
nursing actions/interventions
Single adult alone, 522
preschoolers, 368369
Setting priorities, 5
tissue integrity, impaired, 182
toddlers and preschoolers, 383
628
clinical concerns, 370
NANDA taxonomy, Nursing Interventions
Classication, 621
NANDA taxonomy, Nursing Interventions
nursing actions/interventions
nursing actions/interventions
Classication, Nursing Outcomes
adult health, 580581
Classication, 628
denition of, 375
nutrition, imbalanced, less than body
nursing actions/interventions
differential diagnosis, 376
requirements, 157
INDEX 749
Sorrow, chronic
clinical concerns, 337
home health, 84
Classication, 591
adult health, 337338
clinical concerns, 173
nursing actions/interventions
child health, 338339
denition of, 173
Spiritual distress
Startle response, 383
expected outcome, 174, 177
actual, 683
Stillborn, nursing actions/interventions
owchart evaluation, 177
anxiety, 457
Stress
womens health, 175
grieving
denition of, 634
related factors, 173
anticipatory, 544
psychosocial-cultural, 634
by infants, 89
dysfunctional, 551
Stress response, levels of, 634
phases of
requirements, 157
denition of, 633
oral preparatory phase, 87
enhanced, 689
Stroke volume, cardiac output and, 262
Symbolic interaction, 452, 522
Classication, 683
553
Symptoms, in diagnostic statement, 4
nursing actions/interventions
Suffocation, 42
Syntaxic mode, 452
nursing actions/interventions
Surgical recovery, delayed
Tertiary prevention, 18
750 INDEX
Therapeutic regimenContinued
clinical concerns, 440
gastrointestinal, 341
denition of, 57
denition of, 440
NANDA taxonomy, Nursing Interventions
differential diagnosis, 57
differential diagnosis, 440
Classication, Nursing Outcomes
Outcomes Classication, 57
environmental interpretation syndrome,
adult health, 342343
nursing actions/interventions
impaired, 406
child health, 343344
child health, 58
hopelessness, 484
owchart evaluation, 349
owchart evaluation, 60
injury, risk for, 43
home health, 348
gerontic health, 59
knowledge, decient, 410
psychiatric health, 346347
home health, 59
memory, impaired, 416
target dates, 341
target dates, 57
powerlessness, 501
peripheral, 341
womens health, 58
self-care decit, 331
related factors, 341
ineffective management of
sensory perception, disturbed, 431
renal, 341
characteristics of, 61
therapeutic regimen, ineffective
Todays Caregiver, 530
clinical concerns, 62
management of, 62
Toddlers. See also Infants
for communities, 61
wandering, 360
activity-exercise pattern, 227228
denition of, 61
NANDA taxonomy, Nursing Interventions
cognitive-perceptual pattern, 383
differential diagnosis, 62
Classication, Nursing Outcomes
copingstress tolerance pattern, 635
for individuals, 61
expected outcome, 440, 446
role-relationship pattern, 523524
Outcomes Classication, 61
home health, 444445
sexuality-reproductive pattern,
noncompliance, 61
psychiatric health, 442443
612613
nursing actions/interventions
target dates, 440
sleep-rest pattern, 368369
owchart evaluation, 70
Tissue integrity
value-belief pattern, 683
gerontic health, 68
denition of, 8889 visual development, 383
target dates, 62
clinical concerns, 182
228
womens health, 65
denition of, 181
Toileting self-care decit, 330
Thermoregulation
infection, risk for, 37
Total lung capacity, denition of, 240t
ineffective
nursing actions/interventions
Total urinary incontinence, 211
for, 102
home health, 189
adults and older adults, 385
hyperthermia, 140
target dates, 182
toddlers and preschoolers, 383
hypothermia, 145
womens health, 185187
during pregnancy, 435
nursing actions/interventions
cerebral, 341
denition of, 350
INDEX 751
Trauma, 4243. See also Injury, risk for; NANDA taxonomy, Nursing Interventions
denition of, 602610
continuous, 159160
adult health, 219220
injury, risk for, 43
Underweight, 88
owchart evaluation, 223
NANDA taxonomy, Nursing Interven
-
Unilateral neglect
gerontic health, 221
tions Classication, Nursing
Classication, 447
Urination, process of, 193
gerontic health, 608
nursing actions/interventions
Urine volume, 193
home health, 608609
actions/interventions, 401
infants, 682683
infants, 382383
Urinary incontinence
young adults, 683
functional, 211
Ventilatory weaning response. See NANDA taxonomy, Nursing Interventions
Classication, 211
Verbal communication, impaired
nursing actions/interventions
nursing actions/interventions
characteristics of, 596
adult health, 356357
reex, 211
nursing actions/interventions
characteristics of, 360
stress, 211
child health, 597598
denition of, 360
total, 211
expected outcome, 596, 601
differential diagnosis, 360
urge, 211
owchart evaluation, 601
NANDA taxonomy, Nursing Interventions
Urinary retention
psychiatric health, 598600
nursing actions/interventions
752 INDEX
WanderingContinued
nursing actions/interventions
Women, nursing actions/interventions for.
psychiatric health, 361
adult health, 364
See specic nursing diagnosis
target dates, 360
child health, 364365
Classication, 364
Wisdom teeth, 91
value-belief pattern, 683