Sparks and Taylor's Nursing Diagnosis Pocket Guide

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SPARKS AND TAYLORS
Nursing Diagnosis
Pocket Guide
Sheila Sparks Ralph, RN, PhD, FAAN

Professor, Division of Nursing
Shenandoah University
Winchester, VA
Member of NANDA-I Foundation
Philadelphia
Cynthia M. Taylor, RN, MS

Nurse Consultant
Coordinator, Parish Nurse Program
St. Michaels Church
Kailua Kona, HI
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Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
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9 8 7 6 5 4 3 2 1
Printed in China
Library of Congress Cataloging-in-Publication Data

Ralph, Sheila Sparks.
Sparks and Taylors nursing diagnosis pocket guide / Sheila Sparks
Ralph, Cynthia M. Taylor.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-58255-733-5
1. Nursing diagnosisHandbooks, manuals, etc. I. Taylor, Cynthia M.
II. Title. III. Title: Nursing diagnosis pocket guide.
[DNLM: 1. Nursing DiagnosismethodsHandbooks. WY 49 R163sa 2011]
RT48.6.R35 2011
616.07'5dc22
2009028540
Care has been taken to confirm the accuracy of the information presented and
to describe generally accepted practices. However, the authors, editors, and publisher
are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended
may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that
drug selection and dosage set forth in this text are in accordance with the current rec-
ommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new
or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and
Drug Administration (FDA) clearance for limited use in restricted research settings.
It is the responsibility of the healthcare provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
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CONTRIBUTORS
Marcia Perkins, MSN, RN

Adjunct Clinical Instructor, Division of Nursing
Winchester, VA
Helen H. Mautner, MSN, RN

Assistant Professor, Division of Nursing
Winchester, VA
Anne Z. Cockerham, PhD, CNM

Course Coordinator
Frontier School of Midwifery and Family Nursing
Hyden, KY
Jennifer Matthews, PhD, RN

Associate Professor, Division of Nursing
Winchester, VA
Billinda Tebbenhoff, MSN, RN

Adjunct Clinical Instructor, Division of Nursing
Winchester, VA
Sherry Rawls-Bryce, MSN, RN

Adjunct Assistant Professor, Division of Nursing
Winchester, VA
Maryann Valcourt, MSN, CPNP

Assistant Professor
Trinity University
Washington, DC
iii
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PREFACE
For student nurses as well as expert clinicians, Sparks and Taylors

Nursing Diagnosis Pocket Guide offers a clearly written, authoritative
care plan for each of the NANDA International (NANDA-I) approved
nursing diagnoses to help meet patients healthcare needs. The guide
is organized using a unique assessment framework based on the NNN
Taxonomy of Nursing Practice: A Common Unifying Structure for
Nursing Language (Dochterman & Jones, 2003) and the intervention
terms from the International Classification for Nursing Practice
(ICNP Version 1; International Council of Nurses, 2005). This
framework provides a comprehensive yet easy-to-use format for writ-
ing plans of care for clients. The book also includes the linkages
between NANDA-I and the Nursing Interventions Classification (NIC)
and Nursing Outcomes Classification (NOC) labels. Youll find the
care plans in this book, which are designed for easy use with a left-
and right-page sequence, are invaluable in every healthcare setting you
encounter throughout your career.
GUIDELINES FOR USING SPARKS AND TAYLORS NURSING

DIAGNOSIS POCKET GUIDE
All care plans contain the following sections:
Diagnostic statement. Each diagnostic statement includes a
NANDA-I-approved diagnosis. The Sparks and Taylors Nursing
Diagnosis Pocket Guide contains all the diagnoses approved by
NANDA-I through 2009.
Definition. Each diagnosis is explained with a NANDA-I
approved definition.
Defining characteristics. This section lists clinical findings that confirm
the diagnosis. For diagnoses expressing the possibility of a problem,
such as Risk for Injury, this section is labeled Risk Factors.
Assessment. This section suggests parameters to use when collect-
ing data to ensure an accurate diagnosis. Complete assessment
parameters are presented in Appendix A. The parameters are
based on the NNN Taxonomy of Nursing Practice and include
four domains: functional, physiological, psychosocial, and
environmental (see Appendix A). The domains are subdivided
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vi Preface
into classes; each class includes key subjective and objective data
to be assessed. For each plan, the authors have indicated the
parameters that are most necessary for that diagnosis.
Expected outcomes. Here youll find realistic goals for resolving
or ameliorating the patients health problem, written in measura-
ble behavioral terms. You should select outcomes that are appro-
priate to the condition of your patient. Outcomes are arranged
to flow logically from admission to discharge of the patient.
Outcomes identified by NOC research are included for your con-
sideration.
Interventions and rationales. This section provides specific
activities you carry out to help attain expected outcomes. Inter-
ventions are organized using the following terms: determine,
perform, inform, attend, and manage. These intervention types
use the International Classification of Nursing Practice
taxonomy that is explained in more detail later in these guide-
lines. Each intervention contains a rationale, highlighted in
italic. Rationales receive typographic emphasis because they
form the premise for every nursing action. Youll find it helpful
to consider rationales before intervening. Understanding the why
of your actions can help you see that carrying out repetitive or
difficult interventions is an essential element of your nursing
practice. More importantly, it can improve critical thinking and
help you avoid mistakes. Interventions from NIC research are
included for your consideration.
Reference. Each plan concludes with a reference that you may
find useful if you need further information about the nursing
diagnosis.
NURSING PROCESS OVERVIEW

The cornerstone of clinical nursing, the nursing process, is a system-
atic method for taking independent nursing action. Steps in the
nursing process include the following:
assessing the patients problems
forming a diagnostic statement
identifying expected outcomes
creating a plan to achieve expected outcomes
implementing the plan or assigning steps for implementation to
others
evaluating the plans effectiveness
These phases of the nursing processassessment, nursing diagnosis
formation, outcome identification, care planning, implementation,
and evaluationare dynamic and flexible; they commonly overlap.
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Preface vii
Becoming familiar with this process has many benefits. It will
allow you to apply your knowledge and skills in an organized, goal-
oriented manner. It will also enable you to communicate about pro-
fessional topics with colleagues from all clinical specialties and prac-
tice settings. Using the nursing process is essential to documenting
nursings role in the provision of comprehensive, quality patient
care.
By clearly defining those problems a nurse may treat independently,
the nursing process has helped dispel the notion that nursing practice
is based solely on carrying out physicians orders. Nurse researchers
and expert practitioners continue to develop a body of knowledge
specific to the field. Nursing literature is providing direction to stu-
dents and seasoned practitioners for evidence-based practice. A
strong foundation in the nursing process will enable you to better
assimilate emerging concepts and to incorporate these concepts into
your practice.
Assessment
The vital first phase in the nursing processassessmentconsists of
the patient history, the physical examination, and pertinent diagnos-
tic studies. The other nursing process phases depend on the quality
of the assessment data for their effectiveness.
Your initial patient assessment begins with the collection of
data (patient history, physical examination findings, and diagnostic
study data) and ends with a statement of the patients nursing
diagnosis(es).
Building a database
The information you collect in taking the patients history, perform-
ing a physical examination, and analyzing test results serves as your
assessment database. Your goal is to gather and record information
that will be most helpful in assessing your patient. You cant realisti-
cally collector useall the information that exists about the
patient. To limit your database appropriately, ask yourself the
following questions:
What data do I want to collect?
How should I collect the data?
How should I organize the data to make care planning decisions?
Your answers will help you be selective in collecting meaningful data
during patient assessment.
The well-defined database for a patient may begin with admission
signs and symptoms, chief complaint, or medical diagnosis. It may
also center on the type of patient care given in a specific setting,
such as the intensive care unit, the emergency department, or an
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outpatient care center. For example, you wouldnt ask a trauma vic-
tim in the emergency department whether she has a family history
of breast cancer, nor would you perform a routine breast examina-
tion on her. You would, however, do these types of assessment dur-
ing a comprehensive health checkup in an outpatient care setting.
If you work in a setting where patients with similar diagnoses are
treated, choose your database from information pertinent to this
specific patient population. Even when addressing patients with simi-
lar diagnoses, however, complete a thorough assessment to make
sure that unanticipated problems dont go unnoticed.
Collecting Subjective and Objective Data

The assessment data you collect and analyze fall into two important
categories: subjective and objective. The patients history, embodying
a personal perspective of problems and strengths, provides subjective
data. Its your most important assessment data source. Because its
also the most subjective source of patient information, it must be
interpreted carefully.
In the physical examination of a patientinvolving inspection,
palpation, percussion, and auscultationyou collect one form of
objective data about the patients health status or about the patho-
logic processes that may be related to his illness or injury. In addi-
tion to adding to the patients database, this information helps you
interpret his history more accurately by providing a basis for com-
parison. Use it to validate and amplify the historical data. However,
dont allow the physical examination to assume undue importance
formulate your nursing diagnosis by considering all the elements of
your assessment, not just the examination.
Laboratory test results are another objective form of assessment
data and the third essential element in developing your assessment.
Laboratory values will help you interpretand usually clarifyyour
history and physical examination findings. The advanced technology
used in laboratory tests enables you to assess anatomic, physiologic,
and chemical processes that cant be assessed subjectively or by phys-
ical examination alone. For example, if the patient complains of
fatigue (history) and you observe conjunctival pallor (physical exami-
nation), check his hemoglobin level and hematocrit (laboratory data).
Both subjective (history) and objective (physical examination and
laboratory test results) data are essential for comprehensive patient
assessment. They validate each other and together provide more
data than either can provide alone. By considering history, physical
examination, and laboratory data in their appropriate relationships
to one another, youll be able to develop a nursing diagnosis on
which to formulate an effective care plan.
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A patient may request a complete physical checkup as part of
a periodic (perhaps annual) health maintenance routine. Such a
patient may not have a chief complaint; therefore, this patients
health history should be comprehensive, with detailed information
about lifestyle, self-image, family and other interpersonal relation-
ships, and degree of satisfaction with current health status.
Be sure to record health history data in an organized fashion
so that the information will be meaningful to everyone involved in
the patients care. Some healthcare facilities provide patient ques-
tionnaires or computerized checklists. (See assessment parameters
based on NNN Taxonomy of Nursing Practice in Appendix A.)
When documenting the health history, be sure to record negative
findings as well as positive ones; that is, note the absence of symp-
toms that other history data indicate might be present. For example,
if a patient reports pain and burning in his abdomen, ask him
whether he has experienced nausea and vomiting or noticed blood
in his stools. Record the presence or absence of these symptoms.
Remember that the information you record will be used by others
who will be caring for the patient. It could even be used as a legal
document in a liability case, a malpractice suit, or an insurance dis-
ability claim. With these considerations in mind, record history data
thoroughly and precisely. Continue your questioning until youre sat-
isfied that youve recorded sufficient detail.
Dont be satisfied with inadequate answers, such as a lot or
a little; such subjective terms must be explained within the
patients context to be meaningful. If taking notes seems to make
the patient anxious, explain the importance of keeping a written
record. To facilitate accurate recording of the patients answers,
familiarize yourself with standard history data abbreviations.
When you complete the patients health history, it becomes part of
the permanent written record. It will serve as a database with which
you and other healthcare professionals can monitor the patients
progress. Remember that history data must be specific and precise.
Avoid generalities. Instead, provide pertinent, concise, detailed infor-
mation that will help determine the direction and sequence of the
physical examinationthe next phase in your patient assessment.
After taking the patients health history, the next step in the
assessment process is the physical examination. During this assess-
ment phase, you obtain objective data that usually confirm or rule
out suspicions raised during the health history interview.
Use four basic techniques to perform a physical examination:
inspection, palpation, percussion, and auscultation (IPPA). These
skills require you to use your senses of sight, hearing, touch, and
smell to formulate an accurate appraisal of the structures and
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functions of body systems. Using IPPA skills effectively lessens the

chances that youll overlook something important during the physi-
cal examination. In addition, each examination technique collects
data that validate and amplify data collected through other IPPA
techniques.
Accurate and complete physical assessments depend on two inter-
related elements.
One is the critical act of sensory perception, by which you receive
and perceive external stimuli. The other element is the conceptual,
or cognitive, process by which you relate these stimuli to your
knowledge base. This two-step process gives meaning to your assess-
ment data.
Develop a system for assessing patients that identifies their prob-
lem areas in priority order. By performing physical assessments sys-
tematically and efficiently instead of in a random or indiscriminate
manner, youll save time and identify priority problems quickly.
First, choose an examination method. The most commonly used
methods for completing a total systematic physical assessment are
head-to-toe and major body systems.
The head-to-toe method is performed by systematically assessing
the patient byas the name suggestsbeginning at the head and
working toward the toes.
Examine all parts of one body region before progressing to the
next region to save time and to avoid tiring the patient or yourself.
Proceed from left to right within each region so you can make sym-
metrical comparisons; that is, when examining the head, proceed
from the left side of the head to the right side.
After completing both sides of one body region, proceed to the next.
The major body systems method of examination involves system-
atically assessing the patient by examining each body system in pri-
ority order or in an established sequence.
Both the head-to-toe and major body systems methods are system-
atic and provide a logical, organized framework for collecting physi-
cal assessment data.
They also provide the same information; therefore, neither is more
correct than the other. Choose the method (or a variation of it) that
works well for you and is appropriate for your patient population.
Follow this routine whenever you assess a patient, and try not to
deviate from it.
You may want to plan your physical examination around the
patients chief complaint or concern. To do this, begin by examining
the body system or region that corresponds to the chief complaint.
This allows you to identify priority problems promptly and reassures
the patient that youre paying attention to his chief complaint.
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Physical examination findings are crucial to arriving at a nursing
diagnosis and, ultimately, to developing a sound nursing care plan.
Record your examination results thoroughly, accurately, and clearly.
Although some examiners dont like to use a printed form to record
physical assessment findings, preferring to work with a blank paper,
others believe that standardized data collection forms can make
recording physical examination results easier. These forms simplify
comprehensive data collection and documentation by providing a
concise format for outlining and recording pertinent information.
They also remind you to include all essential assessment data.
When documenting, describe exactly what youve inspected, pal-
pated, percussed, or auscultated. Dont use general terms such as
normal, abnormal, good, or poor. Instead, be specific. Include posi-
tive and negative findings. Try to document as soon as possible after
completing your assessment. Remember that abbreviations aid con-
ciseness.
Nursing diagnosis
According to NANDA-I, the nursing diagnosis is a clinical
judgment about individual, family, or community responses to actual
or potential health problems/life processes. A nursing diagnosis
provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable (Herdman, 2009,
p. 419). The nursing diagnosis must be supported by clinical infor-
mation obtained during patient assessment.
Each nursing diagnosis describes a patient problem that a nurse
can professionally and legally manage. Becoming familiar with nurs-
ing diagnoses will enable you to better understand how nursing prac-
tice is distinct from medical practice. Although the identification of
problems commonly overlaps in nursing and medicine, the approach
to treatment clearly differs. Medicine focuses on curing disease; nurs-
ing focuses on holistic care that includes care and comfort.
Nurses can independently diagnose and treat the patients response
to illness, certain health problems and risk for health problems,
readiness to improve health behaviors, and the need to learn new
health information. Nurses comfort, counsel, and care for patients
and their families until theyre physically, emotionally, and spiritually
ready to provide self-care.
The nursing diagnosis expresses your professional judgment of the
patients clinical status, responses to treatment, and nursing care
needs. You perform this step so that you can develop your care
plan. In effect, the nursing diagnosis defines the practice of nursing.
Translating the history, physical examination, and laboratory data
about a patient into a nursing diagnosis involves organizing the data
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into clusters and interpreting what the clusters reveal about the
patients ability to meet basic needs. In addition to identifying the
patients needs in coping with the effects of illness, consider what
assistance the patient requires to grow and develop to the fullest
extent possible. Your nursing diagnosis describes the cluster of signs
and symptoms indicating an actual or potential health problem that
you can identifyand that your care can resolve. Nursing diagnoses
that indicate potential health problems can be identified by the
words risk for that appear in the diagnostic label. There are also
nursing diagnoses that focus on prevention of health problems and
enhanced wellness.
Creating your nursing diagnosis is a logical extension of collecting
assessment data. In your patient assessment, you asked each history
question, performed each physical examination technique, and con-
sidered each laboratory test result because it provided evidence of
how the patient could be helped by your care or because the data
could affect nursing care.
To develop the nursing diagnosis, use the assessment data youve
collected to develop a problem list. Less formal in structure than a
fully developed nursing diagnosis, this list describes the patients
problems or needs. Its easy to generate such a list if you use a con-
ceptual model or an accepted set of criterion norms. Examples of
such norms include normal physical and psychological development
and the assessment parameters based on the NNN Taxonomy of
Nursing Practice (see Appendix A).
You can identify the patients problems and needs with simple
phrases, such as poor circulation, high fever, or poor hydration.
Next, prioritize the problems on the list and then develop the work-
ing nursing diagnosis.
Some nurses are confused about how to document a nursing diag-
nosis because they think the language is too complex. By remember-
ing the following basic guidelines, however, you can ensure that
your diagnostic statement is correct:
Use proper terminology that reflects the patients nursing needs.
Make your statement concise so its easily understood by other
healthcare team members.
Use the most precise words possible.
Use a problem-and-cause format, stating the problem and its
related cause.
Whenever possible, use the terminology recommended by NANDA-I.
NANDA-I diagnostic headings, when combined with suspected eti-
ology, provide a clear picture of the patients needs. Thus, for clarity
in charting, start with one of the NANDA-I categories as a heading
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Preface xiii
for the diagnostic statement. The category can reflect an actual or
potential problem. Consider this sample diagnosis:
Heading: Disturbed Sleep Pattern
Etiology: select the appropriate Related To phrase from the
choices in the care plan
Signs and symptoms: I dont get enough sleep. My husband
wakes me several times during the night to assist him. You note
dark circle under her eyes and some jitteriness. Do not state a
direct cause-and-effect relationship (which may be hard to prove).
Remember to state only the patients problems and the probable
origin. Omit references to possible solutions. (Your solutions will
derive from your nursing diagnosis, but they arent part of it.)
Errors can also occur when nurses take shortcuts in the nursing
process, either by omitting or hurrying through assessment or by
basing the diagnosis on inaccurate assessment data.
Keep in mind that a nursing diagnosis is a statement of a health
problem that a nurse is licensed to treata problem for which
youll assume responsibility for therapeutic decisions and accounta-
bility for the outcomes. A nursing diagnosis is not a:
diagnostic test (schedule for cardiac angiography)

piece of equipment (set up intermittent suction apparatus)
problem with equipment (the patient has trouble using a commode)
nurses problem with a patient (Mr. Jones is a difficult patient;
hes rude and wont take his medication.)
nursing goal (encourage fluids up to 2,000 ml per day)
nursing need (I have to get through to the family that they must
accept the fact that their father is dying.)
medical diagnosis (cervical cancer)
treatment (catheterize after each voiding for residual urine).
At first, these distinctions may not be clear. The following examples

should help clarify what a nursing diagnosis is:
Dont state a need instead of a problem.

Incorrect: Fluid replacement related to fever
Correct: Deficient fluid volume related to fever
Dont reverse the two parts of the statement.
Incorrect: Lack of understanding related to noncompliance with
diabetic diet
Correct: Noncompliance with diabetic diet related to lack of
understanding
Dont identify an untreatable condition instead of the problem it
indicates (which can be treated).
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Incorrect: Inability to speak related to laryngectomy

Correct: Social isolation related to inability to speak because of
laryngectomy
Dont write a legally inadvisable statement.
Incorrect: Skin integrity impairment related to improper posi-
tioning
Correct: Impaired skin integrity related to immobility
Dont identify as unhealthful a response that would be appropri-
ate, allowed for, or culturally acceptable.
Incorrect: Anger related to terminal illness
Correct: Ineffective therapeutic regimen management related to
anger over terminal illness
Dont make a tautological statement (one in which both parts of
the statement say the same thing).
Incorrect: Pain related to alteration in comfort
Correct: Acute pain related to postoperative abdominal disten-
tion and anxiety
Dont identify a nursing problem instead of a patient problem.
Incorrect: Difficulty suctioning related to thick secretions
Correct: Ineffective airway clearance related to thick tracheal
secretions
Outcome identification
During this phase of the nursing process, you identify expected out-
comes for the patient. Expected outcomes are measurable, patient-
focused goals that are derived from the patients nursing diagnoses.
These goals may be short- or long-term. Short-term goals include
those of immediate concern that can be achieved quickly. Long-term
goals take more time to achieve and usually involve prevention,
patient teaching, and rehabilitation.
In many cases, you can identify expected outcomes by converting
the nursing diagnosis into a positive statement. For instance, for the
nursing diagnosis impaired physical mobility related to a fracture
of the right hip, the expected outcome might be The patient will
ambulate independently before discharge.
When writing the care plan, state expected outcomes in terms
of the patients behaviorfor example, the patient correctly
demonstrates turning, coughing, and deep breathing. Also iden-
tify a target time or date by which the expected outcomes should
be accomplished. The expected outcomes will serve as the basis
for evaluating your nursing interventions. Keep in mind that each
expected outcome must be stated in measurable terms. If possible,
consult with the patient and his family when establishing expected
outcomes. As the patient progresses, expected outcomes should be
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increasingly directed toward planning for discharge and follow-up
care.
Outcome statements should be tailored to your practice setting.
For example, in the intensive care unit you may focus on maintain-
ing hemodynamic stability, whereas on a rehabilitation unit you
would focus on maximizing the patients independence and prevent-
ing complications.
When writing expected outcomes in your care plan, always start
with a specific action verb that focuses on the patients behavior. By
telling your reader how the patient should look, walk, eat, drink,
turn, cough, speak, or stand, for example, you give a clear picture
of how to evaluate progress.
The expected outcomes in the Sparks and Taylors Nursing Diagnosis
Pocket Guide all start with the phrase: The patient will... and list
all the appropriate outcomes. You need to choose which ones are
needed for this patient. You will have to specify which person the
goals refer to when family, friends, or others are directly concerned.
The Expected Outcome section is followed by selected outcomes
from the Nursing Outcomes Classification (NOC) list.
Understanding NOC
The NOC is a standardized language of patientclient outcomes
that was developed by a nursing research team at the University of
Iowa. It contains 330 outcomes organized into 29 classes and seven
domains. Each outcome has a definition, a list of measurable indica-
tors, and references. The outcomes are research-based, and studies
are ongoing to evaluate their reliability, validity, and sensitivity. More
information about NOC can be found at the Center for Nursing
Classification and Clinical Effectiveness (www.nursing.uiowa.edu/cnc).
Planning
The nursing care plan refers to a written plan of action designed to
help you deliver quality patient care. It includes relevant nursing
diagnoses, expected outcomes, and nursing interventions. Keep in
mind that the care plan usually forms a permanent part of the
patients health record and will be used by other members of the
nursing team. The care plan may be integrated into an interdiscipli-
nary plan for the patient. In this instance, clear guidelines should
outline the role of each member of the healthcare team in providing
care.
A written care plan gives direction by showing colleagues the
goals you have set for the patient and giving clear instructions
for helping achieve them. If the patient is discharged from your
healthcare facility to another, your care plan can help ease this
transition.
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Selecting appropriate nursing actions (interventions): Next, youll

select one or more nursing interventions to achieve each of the
expected outcomes identified for the patient. For example, if one
expected outcome statement reads The patient will transfer to chair
with assistance, the appropriate nursing interventions include plac-
ing the wheelchair facing the foot of the bed and assisting the
patient to stand and pivot to the chair. If another expected outcome
statement reads The patient will express feelings related to recent
injury, appropriate interventions might include spending time with
the patient each shift, conveying an open and nonjudgmental
attitude, and asking open-ended questions. Interventions used in the
Sparks and Taylors Nursing Diagnosis Pocket Guide are organized
according to the ICNP types (Description of NNN Taxonomy of
Nursing Practice and ICNP, 2005). Because all of your activities are
based on assessment data, Determine is listed first. The interven-
tion types will appear in the following order: Determine, Perform,
Inform, Attend, and Manage. To provide comprehensive care, con-
sider each of the intervention types carefully in your selection.
Reviewing the second part of the nursing diagnosis statement (the
part describing etiologic factors) may help guide your choice of
nursing interventions. For example, for the nursing diagnosis
Impaired individual resistance related to poor impulse control,
you would determine the best nursing interventions for learning
techniques to manage behavior. Try to think creatively during this
step in the nursing process. Its an opportunity to describe exactly
what you and your patient would like to have happen and to estab-
lish the criteria against which youll judge further nursing actions.
The planning phase culminates when you write the care plan and
document the nursing diagnoses, expected outcomes, and nursing
interventions. Write your care plan in concise, specific terms so that
other healthcare team members can follow it. Keep in mind that
because the patients problems and needs will change, youll have to
review your care plan frequently and modify it when necessary.
Implementation
During this phase, you put your care plan into action. Implementa-
tion encompasses all nursing interventions directed toward solving
the patients nursing problems and meeting healthcare needs. While
you coordinate implementation, you also seek help from other care-
givers, the patient, and the patients family.
Implementation requires some (or all) of the following types of
interventions:
Determine: assessing and monitoring (e.g., recording vital signs)
Perform: providing care
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Inform: teaching and counseling
Attend: making the patient more comfortable, giving emotional
support
Manage: referring the patient to appropriate agencies or
services
Although it may be brief or narrowly focused, reassessment should
confirm that the planned interventions remain appropriate.
Implementation isnt complete until youve documented each
intervention, the time it occurred, the patients response, and any
other pertinent information. Make sure each entry relates to a
nursing diagnosis. Remember that any action not documented
may be overlooked during quality assurance monitoring or evalua-
tion of care. Another good reason for thorough documentation: It
offers a way for you to take rightful credit for your contribution
in helping a patient achieve the highest possible level of wellness.
After all, nurses use a unique and worthwhile combination of
interpersonal, intellectual, and technical skills when providing
care.
Understanding Nursing Interventions Classification

The Nursing Interventions Classification (NIC) is a standardized lan-
guage of treatments that was developed by a nursing research team
at the University of Iowa. It contains 514 interventions organized
into 30 classes and seven domains.
Each intervention has a definition, a list of detailed activities, and
references. The interventions are research-based and studies are ongo-
ing to evaluate the effectiveness and cost of nursing treatments. More
information about NIC can be found at the Center for Nursing Clas-
sification and Clinical Effectiveness (www.nursing.uiowa.edu/cnc).
Evaluation
In this phase of the nursing process, you assess the effectiveness of
the care plan by answering such questions as:
How has the patient progressed in terms of the plans projected
outcomes?
Does the patient have new needs?
Does the care plan need to be revised?
Evaluation also helps you determine whether the patient received
high-quality care from the nursing staff and the healthcare facility.
Your facility bases its own nursing quality assurance system on nurs-
ing evaluations.
Include the patient, family members, and other healthcare profes-
sionals in the evaluation. Then, follow the following steps:
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xviii Preface
Select evaluation criteria. The care plans projected outcomesthe

desired effects of nursing interventionsform the basis for evalu-
ation.
Compare the patients response with the evaluation criteria. Did the
patient respond as expected? If not, the care plan may need revision.
Analyze your findings. If your plan wasnt effective, determine
why. You may conclude, for example, that several nursing diag-
noses were inaccurate.
Modify the care plan. Make revisions (e.g., change inaccurate
nursing diagnoses) and implement the new plan.
Reevaluate. Like all steps in the nursing process, evaluation is
ongoing. Continue to assess, plan, implement, and evaluate for as
long as you care for the patient.
DESCRIPTION OF NNN TAXONOMY OF NURSING

PRACTICE AND ICNP
Two organizing frameworks are used in the Sparks and Taylors Nurs-
ing Diagnosis Pocket Guide: The NNN Taxonomy of Nursing Prac-
tice and intervention terms from the International Classification of
Nursing Practice. Each of the frameworks is described in this section.
We recommend that you get more information about these from the
references cited.
NNN Taxonomy of Nursing Practice
The NNN Taxonomy of Nursing Practice (NNNTNP) consists of
nursing diagnoses, nursing interventions, and nursing outcomes
developed as the result of an invitational conference funded by
the National Library of Medicine in 2001 (Dochterman & Jones,
2003). Leaders in nursing language development from NANDA-I
for nursing diagnoses, the Center for Nursing Classification
and Clinical Effectiveness at the University of Iowa for nursing
outcomes and nursing interventions, and selected other experts
convened to develop a common unifying taxonomy to further the
development, testing, and refinement of nursing language. Results
of their efforts were published in Unifying Nursing Languages: The
Harmonization of NANDA, NIC, and NOC (Dochterman & Jones,
2003) and NANDA International Nursing Diagnoses: Definitions
and Classification 20032004 (Ralph, Craft-Rosenberg, Herdman,
& Lavin, 2003). Since that time the NANDA Taxonomy Committee
has placed new diagnoses in the taxonomy (Herdman, 2009).
The NNNTNP has four domains and 28 classes. The domains,
classes, and their definitions are depicted in Appendix B. Assess-
ment parameters based on the taxonomy were developed for the
Sparks and Taylors Nursing Diagnosis Pocket Guide.
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International Classification for Nursing Practice
There has been universal agreement among nurses about the impor-
tance of recognizing our practice parameters since the time of Flo-
rence Nightingale. A resolution to establish an International Classifi-
cation for Nursing Practice (ICNP) was passed by the International
Council of Nurses (ICN) in 1989. The components of the ICNP
describe the elements of nursing practice: what nurses do relative
to certain human needs to produce certain results (nursing interven-
tions, diagnoses, and outcomes) (ICN, 2005, p. 11).
The ICNP is a unified nursing language system. It consists of a
multiaxial model intended to be a resource in developing
information systems for nursing globally. The 7 axes include Focus,
Judgment, Means, Action, Time, Location, and Client. The Sparks
and Taylors Nursing Diagnosis Pocket Guide uses the Action Axis
for the basis of selecting nursing interventions. The terms used are
Determine, Perform, Inform, Attend, and Manage. Each of these
terms is further defined in Appendix C. Each care plan in the Sparks
and Taylors Nursing Diagnosis Pocket Guide uses at least one of
each type of intervention and they are always listed in the order
above.
References
Dochterman, J. M., & Jones, D. A. (Eds.). (2003). Unifying nursing
languages: The Harmonization of NANDA, NIC, and NOC. Washington,
DC: NursesBooks.org.
Herdman, T. H. (2009). NANDA International nursing diagnoses: Definitions
and classification 20092011. West Sussex, UK: Wiley-Blackwell.
International Council of Nurses. (2005). International classification for nursing
practice. Geneva, Switzerland: Author.
Ralph, S. S., Craft-Rosenberg, M., Herdman, T. H., & Lavin, M. A., (2003).
NANDA Nursing Diagnoses & Classification. Philadelphia: NANDA Inter-
national.
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ACKNOWLEDGMENTS
We would like to express our sincere appreciation to the nurses who

contributed to the Nursing Diagnosis Pocket Guide. Their expertise
and commitment to quality patient care made this work possible.
We are also grateful to Helene Caprari and Jean Rodenberger from
Lippincott Williams & Wilkins for their assistance and enthusiastic
support of our work.
Finally, we dedicate this book to nursing students and clinicians
who are striving to provide quality care in todays challenging
healthcare arena.
Sheila Sparks Ralph, RN, PhD, FAAN

Cynthia M. Taylor, RN, MS
xxi
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CONTENTS
PREFACE
Guidelines for Using Sparks and Taylors Nursing Diagnosis

Pocket Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Nursing Process Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Description of NNN Taxonomy of Nursing Practice

and ICNP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
PA R T 1
Nursing Diagnoses Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . 1
PA R T 2
Selected Nursing Diagnoses by Medical Diagnosis . . . . . . . . . 417
APPENDICES
APPENDIX A Assessment Parameters Based on
Taxonomy of Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . 458
APPENDIX B Taxonomy of Nursing Practice: A Common

Unified Structure for Nursing Language . . . . . . . . . . . . . . . . 468
APPENDIX C Action Intervention Types . . . . . . . . . . . . . . . 470
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
xxiii
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PA R T O N E
Nursing Diagnoses
Care Plans
1
INEFFECTIVE ACTIVITY PLANNING

DEFINITION
Inability to prepare for a set of actions fixed in time and under
certain conditions
DEFINING CHARACTERISTICS
Verbalization of fear toward a task to be undertaken
Verbalization of worries toward a task to be undertaken
Excessive anxieties toward a task to be undertaken
Failure pattern of behavior
Procrastination
Unmet goals for chosen activity
Lack of sequential organization
Lack of plan
RELATED FACTORS
Lack of family support Hedonism
Lack of friend support Compromised ability to
Unrealistic perception of events process information
Defensive flight behavior when
faced with proposed solution
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
Behavior Roles/relationships
Communication Self-perception
EXPECTED OUTCOMES
The patient will
Demonstrate improved self-confidence to accomplish tasks.
Demonstrate improved concentration in task planning and execution.
Minimize procrastination.
Articulate personal goals for activity planning and completion.
Verbalize diminished fear and anxiety concerning task planning
and execution.
SUGGESTED NOC OUTCOMES
Cognition; Cognition Orientation; Concentration; Decision-Making;
Information Processing; Memory
INTERVENTIONS AND RATIONALES
Determine: Assess patients concerns related to activity planning and
execution to be able to suggest strategies to overcome challenges.
Perform: Model effective techniques for planning and executing
activities. Patients who are challenged by planning and executing
activities often find it helpful to observe practical approaches instead
of solely hearing theoretical information.
Inform: Teach behavior management strategies to help the person
minimize fears of failure.
3
Attend: Praise successes in any steps of planning or executing activi-
ties; positive reinforcement enhances self-confidence.
Manage: Refer or comanage with behavioral specialists. Colleagues
in related disciplines bring valuable additional perspectives to these
complex clinical situations.
SUGGESTED NIC INTERVENTIONS
Anxiety Reduction; Behavior Management; Behavior Modification;
Calming Technique; Memory Training; Planning Assistance;
Sequence Guidance
Reference
Adler, D. A., McLaughlin, T. J., Rogers, W. H., Chang, H., Lapitsky, L., &
Lerner, D. (2006). Job performance deficits due to depression. American
Journal of Psychiatry, 163, 15691576.
ACTIVITY INTOLERANCE
DEFINITION
Insufficient physiological or psychological energy to endure or com-
plete required or desired daily activities
Abnormal blood pressure and heart rate response to activity
Electrocardiographic changes reflecting arrhythmias and/or ischemia
Exertional discomfort and/or dyspnea
Verbal report of fatigue and/or weakness
RELATED FACTORS
Bed rest Immobility
Generalized weakness Sedentary lifestyle
Imbalance between oxygen
supply and demand
Activity/exercise
Cardiac function
Respiratory function
EXPECTED OUTCOMES
The patient will
Regain and maintain muscle mass and strength.
Maintain maximum joint range of motion (ROM).
Perform isometric exercises.
Help perform self-care activities.
Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
State understanding of and willingness to cooperate in maximizing
the activity level.
Perform self-care activities to tolerance level.
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
Activities of Daily Living (ADLs); Self-Care: Instrumental Activities
of Daily Living (IADLs)
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure, to
ensure that these return to normal within 25 min after stopping
exercise.
Perform: Perform active or passive ROM exercises to all extremities
every 24 hr. These exercises foster muscle strength and tone, main-
tain joint mobility, and prevent contractures.
Turn and reposition patient at least every 2 hr. Establish a turning
schedule for the dependent patient. Post schedule at bedside and
5
monitor frequency. Turning and repositioning prevent skin
breakdown and improve lung expansion and prevent atelectasis.
Maintain proper body alignment at all times to avoid
contractures and maintain optimal musculoskeletal balance and
physiologic function.
Encourage active exercise: Provide a trapeze or other assistive
device whenever possible. Such devices simplify moving and turning
for many patients and allow them to strengthen some upper-body
muscles.
Inform: Teach about isometric exercises to allow patients to maintain
or increase muscle tone and joint mobility.
Teach caregivers to assist patients with ADLs in a way that maxi-
mizes patients potential. This enables caregivers to participate in
patients care and encourages them to support patients
independence.
Attend: Provide emotional support and encouragement to help
improve patients self-concept and motivate patient to perform
ADLs.
Involve patient in planning and decision making. Having the abil-
ity to participate will encourage greater compliance with the plan
for activity.
Have patient perform ADLs. Begin slowly and increase daily, as
tolerated. Performing ADLs will assist patient to regain independence
and enhance self-esteem.
Manage: Refer to case manager/social worker to ensure that a home
assessment has been done and that whatever modifications were
needed to accommodate the patients level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Shin, Y., Yun, S., Jang, H., & Lim, J. (2006). A tailored program for the pro-
motion of physical exercise among Korean adults. Applied Nursing
Research, 19(2), 8894.
RISK FOR ACTIVITY INTOLERANCE

DEFINITION
At risk for experiencing insufficient physiological or psychological
energy to endure or complete required or desired activity
RISK FACTORS
Circulatory or respiratory Inexperience with a particular
problems activity
History of previous intolerance Deconditioned status
Activity/exercise
Cardiac function
EXPECTED OUTCOMES
The patient will
Maintain muscle strength and joint ROM.
Carry out isometric exercise regimen.
Communicate understanding of rationale for maintaining activity
level.
Avoid risk factors that may lead to activity intolerance.
Maintain blood pressure, pulse, and respiratory rate within
prescribed range during periods of activity (specify).
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
ADLs; Self-Care: IADLs
Determine: Assess patients level of functioning using the functional
mobility scale to determine patients capabilities.
Assess patients physiologic response to increased activity (blood
pressure, respirations, heart rate, and rhythm). Monitoring vital
signs helps assess tolerance for increased exertion and activity.
Perform: Position patient to maintain proper body alignment. Use
assistive devices as needed to maintain joint function and prevent
musculoskeletal deformities.
Turn and position patient at least every 2 hr. Establish turning
schedule for the dependent patient. Post at bedside and monitor fre-
quency. Turning helps prevent skin breakdown by relieving pressure.
Unless contraindicated, perform ROM exercises every 24 hr.
Progress from passive to active, according to patient tolerance.
ROM exercises prevent joint contractures and muscular atrophy.
Encourage active movement by helping patient use trapeze or
other assistive devices to improve muscle tone and enhance self-
esteem.
7
Inform: Teach patient how to perform isometric exercises to
maintain and improve muscle tone and joint mobility.
Teach patient, family member, or other caregiver skills such as
placing joints in proper body alignment or correct positioning to
maximize patients participation in self-care. Informed caregivers can
encourage patient to become more independent.
Teach patient symptoms of overexertion, such as dizziness, chest
pain, and dyspnea, to help him or her take responsibility for moni-
toring his or her own activity level.
Assist patient in carrying out self-care activities. Increase patients
participation in self-care, as tolerated, to foster independence and
improve mobility.
Attend: Encourage patient to become involved in planning care and
making decisions related to treatment. Participation in planning
enhances patient compliance.
Explain rationale for maintaining or improving activity level. Dis-
cuss factors that increase the risk of activity intolerance. Education
helps patient avoid activity intolerance.
Encourage patient to carry out ADLs. Provide emotional support,
and offer positive feedback when the patient displays initiative.
Offering emotional support enhances patients self-esteem and moti-
vation.
Manage: Communicate patients level of functioning to all staff.
Communication among staff members ensures continuity of care and
enables patient to preserve the identified level of independence.
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Killey, B., & Watt, E. (2006, July). The effect of extra walking on the mobil-
ity, independence, and exercise self-efficacy of elderly patients: A pilot study.
Contemporary Nurse, 22(1), 120133.
DEFICIENT DIVERSIONAL ACTIVITY

DEFINITION
Decreased stimulation from (or interest or engagement in)
recreational or leisure activities
Usual hobbies are not performed in hospital setting.
Patient states feelings of boredom or wishing for something to do.
RELATED FACTORS
Environmental lack of diversional activity
Cardiac function Physical status
Emotional status Respiratory function
Neurocognition
EXPECTED OUTCOMES
The patient will
Express interest in using leisure time meaningfully.
Express interest and participate in activities that can be provided
(e.g., watch selected television program, listen to radio or music
daily).
Report satisfaction with use of leisure time.
Modify environment to provide maximum stimulation (e.g.,
hanging posters or cards and moving bed next to a window).
Leisure Participation; Motivation; Social Involvement
Determine: Assess leisure activity preferences. Identify the type of music
patient prefers; seek help from family and hospital resources to provide
selected music daily that relieves boredom and stimulates interest.
Perform: Provide supplies and set time to indulge in hobby. Obtain
radio, television, or crochet hook and yarn (if desired). Allow
patient to (if TV or radio) select programs. Communicate patients
desires to coworkers (e.g., Turn on television set at _____ [time]
to _____ [channel]. Give crochet hook and yarn to patient daily
at _____ [time]). Specifying time for activity indicates its value.
Avoid scheduling activities during leisure time, which is integral
to quality of life.
Ask volunteers (friends, family, or hospital volunteer) to read
newspapers, books, or magazines to patient at specific times.
Personal contact helps alleviate boredom.
Engage patient in conversation while carrying out routine care.
Discuss patients favorite topics as much as possible. Conversation
conveys caring and recognition of patients worth.
9
Provide talking books or I-Pod if available. These provide low-
effort sources of enjoyment for bedridden patient.
Obtain an adapter for television to provide captions for hearing-
impaired patient.
Provide plants for the patient to tend to. Caring for live plants
may stimulate interest.
Change scenery when possible; for example, take the patient out-
side in a wheelchair to help reduce boredom.
Attend: Encourage discussion of previously enjoyed hobbies,
interests, or skills to direct planning of new activities. Suggest per-
forming an activity helpful to others or otherwise productive to pro-
mote interest.
Encourage patients family or caregiver to bring personal articles
(posters, cards, and pictures) to help make environment more stimu-
lating (the patient may respond better to objects with personal
meaning).
Manage: Make referral to recreational, occupational, or physical
therapist for consultation on adaptive equipment to carry out
desired activity; arrange for therapy sessions. Adaptive equipment
allows patient to continue enjoying activities or may stimulate inter-
est in new activities.
Activity Therapy; Animal-Assisted Therapy; Art Therapy; Recreation
Therapy
Reference
Wheeler, S. L., & Houston, K. (2005, MarchApril). The role of diversional
activities in the general medical hospital setting. Holistic Nursing Practice,
19(2), 8789.
INEFFECTIVE AIRWAY CLEARANCE

DEFINITION
Inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway
Adventitious breath sounds, Difficulty vocalizing
such as crackles, rhonchi, and Dyspnea
wheezes Ineffective or absent cough
Changes in respiratory rate Orthopnea
and rhythm Restlessness
Cyanosis Sputum production
Diminished breath sounds Wide-eyed
RELATED FACTORS
Environmental: second-hand smoke, smoke inhalation, smoking
Physiological: allergic airways, asthma, chronic obstructive
pulmonary disease, infection, neuromuscular dysfunction, and
hyperplasia of the bronchial walls
Obstructed airway: airway spasm, excessive mucus, exudate in the
alveoli, foreign body in airway, presence of artificial airway,
retained secretions, secretions in the bronchi
Activity/exercise
Cardiac function
EXPECTED OUTCOMES
The patient will
Maintain patent airway.
Have no adventitious breath sounds.
Have a normal chest x-ray.
Have an oxygen level in normal range.
Breathe deeply and cough to remove secretions.
Expectorate sputum.
Demonstrate controlled coughing techniques.
Have adequate ventilation.
Demonstrate skill in conserving energy while attempting to clear
airway.
State understanding of changes needed to diminish oxygen demands.
Aspiration Prevention; Respiratory Status: Airway Patency; Respira-
tory Status: Ventilation
Determine: Assess respiratory status at least every 4 hr or according
to established standards. Obstruction in the airway leads to atelectasis,
11
pneumonia, or respiratory failure. Monitor arterial blood gases val-
ues and hemoglobin levels to assess oxygenation and ventilatory
status. Report deviations from baseline levels; oxygen saturation
should be higher than 90%.
Monitor sputum, noting amount, odor, and consistency. Sputum
amount and consistency may indicate hydration status and effectiveness
of therapy. Foul-smelling sputum may indicate respiratory infection.
Perform: Turn patient every 2 hr; place the patient in lateral, sitting,
prone, and upright positions as much as possible for maximal aera-
tion of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest expansion
and ventilation.
Suction, as ordered, to stimulate cough and clear airways. Be alert
for progression of airway compromise. Perform postural drainage,
percussion, and vibration to facilitate secretion movement.
Provide adequate humidification to loosen secretions. Administer
expectorants, bronchodilators, and other drugs, as ordered, and moni-
tor effectiveness. Provide bronchodilator treatments before chest phys-
iotherapy to optimize results of the treatment. Administer oxygen, as
ordered, to promote oxygenation of cells throughout the body.
Inform: Teach patient an easily performed cough technique to clear
airway without fatigue.
Attend: Avoid placing patient in a supine position for extended peri-
ods to prevent atelectasis.
When helping the patient cough and deep-breathe, use whatever
position best ensures cooperation and minimizes energy expenditure,
such as high Fowlers position or sitting on side of bed. Such posi-
tions promote chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (34 qt [34 L/day]) to ensure
optimal hydration and loosening of secretions, unless contraindicated.
Encourage sputum expectoration to remove pathogens and prevent
spread of infection. Provide tissues and paper bags for hygienic
disposal.
Manage: If conservative measures fail to maintain partial pressure of
arterial oxygen (PaO2) within an acceptable range, prepare for endo-
tracheal intubation, as ordered, to maintain artificial airway and
optimize PaO2 Level.
Airway Management; Aspiration Precautions; Cough Enhancement;
Oxygen Therapy; Respiratory Monitoring; Ventilation Assistance
Reference
Cigna, J. A., & Turner-Cigna, L. M. (2005, September). Rehabilitation for the
home care patient with COPD. Home Healthcare Nurse, 23(9), 578584.
LATEX ALLERGY RESPONSE

DEFINITION
A hypersensitive reaction to natural latex rubber products
Immediate reactions (1 hr of exposure) can be life-threatening
Contact urticaria progressing to generalized symptoms
Edema of the lips, eyelids, sclera, tongue, uvula, and/or throat
Shortness of breath or tightness in the chest, wheezing or
bronchospasm leading to respiratory arrest
Hypotension, syncope, and cardiac arrest
Abdominal pain or nausea
Complaints of increasing body warmth and/or restlessness
Erythema, itching, and/or tearing of the eyes and/or face
Nasal congestion, erythema, itching, and/or rhinorrhea
Type 1V Reactions (1 hr after exposure)
Generalized discomfort
Eczema, irritation, and/or redness
RELATED FACTORS
Absent immune system response
Hypersensitivity to natural latex rubber
Cardiac function
Tissue integrity
EXPECTED OUTCOMES
The patient will
Regain vital signs, respiratory status, and laboratory values.
Exhibit skin that is moist, clear, and free of erythema, edema, itch-
ing, urticaria, and breakdown.
Express awareness of allergic response to latex-containing products.
Comfort Level; Immune Hypersensitivity Response; Knowledge:
Infection Control; Tissue Integrity: Skin and Mucous Membrane
Determine: Determine whether patient has had past episodes of latex
allergy; food, pollen, or drug allergy. Report contacts with latex
products including when, where, and what. History will lead to
more precise assessment.
Monitor respiratory status; include rate, rhythm, skin color, and
breath sounds. Be particularly alert for signs of bronchospasms and
complaints of dyspnea. Assess heart rate, rhythm, and blood pressure.
Check skin carefully for urticaria. Document findings. These measures
detect changes in status to more accurately determine interventions.
13
Remove all latex products from immediate proximity of patient and
staff treating the patient to prevent inadvertent use of products by
staff or patient, increasing the risk for contact and allergic reaction.
Perform: Administer prescribed drugs and treatments as ordered.
Wheezing and shortness of breath can quickly deteriorate to
respiratory distress and failure. Skin with urticaria and itching is
uncomfortable and unsightly so patients appreciate timely adminis-
tration of treatment.
Inform: Teach patient and his or her family to avoid latex products
to prevent future contact and allergic reactions. Provide instruction
about household items that contain latex (provide a written list) and
tell them about nonlatex substitutes. Prevention is the foundation of
treatment of latex allergies.
Instruct patient and his or her family about importance of seeking
immediate medical treatment of allergic reactions to foster timely
intervention.
improve patients self-concept.
Involve patient in planning and decision making, and have him or
her perform self-care activities. Having the ability to participate will
encourage greater compliance with the plan for activity.
Manage: When latex allergy is confirmed, document and label record
clearly to prevent future contact with the allergen.
Emphasize need to inform all healthcare providers about patients
sensitivity to latex. Stress the importance of wearing a medical iden-
tification bracelet that specifies latex allergy to prevent future
contact and allergic reactions.
Provide documentation of latex allergy for the patient to take to
employer; with the patients permission, communicate with employee
health department and discuss patients need to avoid contact with
latex products to prevent further contamination.
Allergy Management; Anaphylaxis Management; Environmental Risk
Protection; Latex Precautions; Risk Identification; Teaching: Individual
Reference
Crippa, M., et al. (2006, August). Prevention of latex allergy among health
care workers and in the general population: Latex protein content in devices
commonly used in hospitals and general practice. International Archives of
Occupational and Environmental Health, 79(7), 550557.
RISK FOR LATEX ALLERGY RESPONSE

DEFINITION
Risk of hypersensitivity to natural latex rubber products
RISK FACTORS
Spina bifida Professions that involve daily
Frequent medical or occupa- exposure to latex
tional exposure to latex Conditions associated with
History of atopy continuous intermittent
History of food allergies, such catheterizations
as allergies to bananas, kiwi, Allergy to poinsettia plants
avocados, chestnuts, or History of reaction to latex
pineapple History of allergies and asthma
Activity/exercise
Nutrition
Tissue integrity
EXPECTED OUTCOMES
The patient will
Regain normal vital signs, respiratory status, and laboratory values.
Exhibit moist, clear skin that is free of erythema, edema, itching,
urticaria, and breakdown.
Express awareness of allergic response to latex-containing products.
Allergy Response: Localized; Immune Hypersensitivity Response;
Risk Control
Determine: Determine whether patient has had past episodes of latex
allergy; food, pollen, or drug allergy. Report contacts with latex
products including when, where, and what. History will lead to
more precise assessment.
Monitor respiratory status; include rate, rhythm, skin color, and
breath sounds. Be particularly alert for signs of bronchospasms and
complaints of dyspnea. Assess heart rate, rhythm, and blood
pressure. Check skin carefully for urticaria. Document findings.
These measures detect changes in patients response to latex or other
substances that cause allergic reactions status.
Remove all latex products from the immediate proximity of the
patient and staff treating the patient to prevent inadvertent use of
latex products by the staff or patient, increasing the risk for contact
and allergic reaction.
Perform: Administer prescribed drugs and treatments as ordered.
Wheezing and shortness of breath can quickly deteriorate to respiratory
distress and failure. Skin with urticaria and itching is uncomfortable
and unsightly so patients appreciate timely administration of treatment.
15
Inform: Educate patient and family about allergic reaction to latex
products to prevent future contact and allergic reactions. Provide a
list of household items containing latex, emphasize importance of
avoiding these, and tell them about nonlatex substitutes. Prevention
is the foundation of treatment of latex allergies.
Educate patient and his or her family about importance of seeking
immediate medical treatment of allergic reactions to foster timely
intervention.
Attend: Involve patient in planning and decision making, and have
the patient perform self-care activities. Having the ability to partici-
pate will encourage greater compliance with the plan for activity.
Manage: Emphasize need to inform all healthcare providers about
sensitivity to latex. Stress importance of wearing a medical identifi-
cation bracelet that specifies possible latex allergy to prevent contact
and allergic reactions.
Provide documentation of the risk of latex allergy for the patient
to take to employer. With patients permission, communicate with
employee health department and discuss patients need to avoid con-
tact with latex products to prevent further contamination.
Allergy Management; Anaphylaxis Management; Environmental Risk
Protection; Latex Precautions; Risk Identification; Teaching: Individual
Reference
Crippa, M., et al. (2006, August). Prevention of latex allergy among health
care workers and in the general population: Latex protein content in devices
commonly used in hospitals and general practice. International Archives of
Occupational and Environmental Health, 79(7), 550557.
ANXIETY
DEFINITION
Vague uneasy feeling of discomfort or dread accompanied by an
autonomic response (the source often non-specific or unknown to
the individual); a feeling of apprehension caused by anticipation of
danger. It is an alerting signal that warns of impeding danger and
enables the individual to take measures to deal with threat
Behavioral: Diminished productivity, fidgeting, restlessness,
scanning and vigilance, poor eye contact, insomnia
Affective: Apprehensive, distressed, fearful, jittery, uncertain, wary
Physiological: Facial tension, hand tremors, increased perspiration,
quivering voice
Sympathetic: Anorexia, cardiovascular excitation, diarrhea, facial
flushing, increased blood pressure and/or pulse, dilated pupils
Parasympathetic: Abdominal pain, decreased blood pressure and/or
pulse, fatigue, nausea, urinary frequency, hesitancy, or urgency
Cognitive: Blocking of thoughts, confusion, impaired attention,
forgetfulness, tendency to blame others
RELATED FACTORS
Threat to self-concept Role change
Situational crises Familial association
Maturational crises Substance abuse
Stress Unconscious conflict about
Unmet needs goals or values
Communication Emotional status
Coping Psychological status
EXPECTED OUTCOMES
The patient will
Identify factors that elicit anxious behaviors.
Participate in activities that decrease feelings of anxious behaviors.
Practice relaxation techniques at specific intervals each day.
Cope with current medical situation without demonstrating severe
signs of anxiety.
Demonstrate observable signs of reduced anxiety.
State that the level of anxiety has decreased.
Anxiety Level; Coping; Grief Resolution; Hyperactivity Level;
Impulse Self-Control; Psychosocial Adjustment: Life Change; Social
Interaction Skills; Stress Level; Symptom Control
Determine: Listen attentively to patient to determine exactly what he or
she is feeling. Listening on the part of the nurse helps the patient
17
identify anxious behaviors more easily and discover the source of
anxiety.
Assess types of activities that help reduce patients stress levels.
Monitor physiologic responses including respirations, heart rate
and rhythm, and blood pressure.
Perform: Reduce environmental stressors (including people), and
remain with patient during severe anxiety. Anxiety often results from
lack of trust in the environment and/or fear of being alone.
Offer relaxing types of music for quiet listening periods. Listening
to relaxing music may have a calming effect.
Promote proper body alignment to avoid contractures and main-
tain optimal musculoskeletal balance and physiologic function.
Encourage active exercise to promote a sense of well-being.
Inform: Teach patient relaxation techniques (guided imagery, progres-
sive muscle relaxation, and meditation) to be performed at least
every 4 hr to restore psychological and physical equilibrium by
decreasing autonomic response to anxiety.
Attend: Provide emotional support and encouragement to improve
self-concept and encourage frequent use of relaxation techniques.
Allow extra visiting times with family if this seems to allay
patients anxiety about activities of daily living.
Involve patient in planning and decision making to encourage
interest and compliance. Encourage patient to talk about the kinds
of activities that promote feelings of comfort. Assist patient to create
a plan to try engaging in at least one of these activities each day.
This gives the patient a sense of control.
Make sure that patient has clear explanations for everything that
will happen to him or her. Ask for feedback to ensure that the
patient understands. Anxiety may impair patients cognitive abilities.
Manage: Refer to case manager/social worker or professional mental
health caretaker to provide mental health assistance. Encouraging
the use of community mental health resources reinforces the fact
that anxiety reduction is a long-term process.
Anger Control Assistance; Anticipatory Guidance; Anxiety
Reduction; Behavior Modification: Social Skills; Calming Technique;
Coping Enhancement; Simple Guided Imagery; Support Group
Reference
Buffin, M. D., et al. (2006, September). A music intervention to reduce anxi-
ety before vascular angiography procedures. Journal of Vascular Nursing,
24(3), 6873.
DEATH ANXIETY
DEFINITION
Vague uneasy feeling of discomfort or dread generated by
perceptions of a real or imagined threat to ones existence
Worry about the impact of ones death on significant others
Powerlessness over issues related to dying
Fear of loss of physical and mental abilities when dying
Total loss of control over aspects of ones own death
Worry about being the cause of others suffering or grief
Fear of leaving family alone after death
Fear of developing a terminal illness
RELATED FACTORS
Anticipating the impact of Uncertainty about life after
death on others death
Anticipating suffering Uncertainty about the
Experiencing the dying process existence of a higher power
Behavior
Communication
Emotional status
EXPECTED OUTCOMES
The patient will
Identify time alone and time needed with others.
Communicate important thoughts and feelings to family members.
Obtain the level of spiritual support desired.
Use available support systems.
Express feelings of comfort and peacefulness.
Acceptance: Health Status; Anxiety Level; Depression Level; Digni-
fied Life Closure; Fear Self-Control; Hope
Determine: Assess how much support the patient desires. Patients
may want a higher degree of independence in dealing with death
than the caregiver wants to allow.
Assess patients spiritual needs. Often as death approaches, indi-
viduals begin thinking more about the needs of the spirit.
Determine which comfort measures the family believes will enhance
feelings of well-being. Dying patients have the right to decide how
much physical, emotional, and spiritual care they wish to have.
Perform: Administer medication to relieve pain and provide comfort
as required. Medicating at an appropriate level does much to relieve
19
pain and often helps the dying person maintain greater feeling of
self-control.
Turn and reposition patient at least every 2 hr. Turning and repo-
sitioning prevent skin breakdown, improve lung expansion, and pre-
vent atelectasis. Establish a turning schedule for the dependent
patient. Post schedule at bedside and monitor frequency.
Provide simple physical gestures of support such as holding hands with
the patient and encouraging family members to do the same. Patient
may want to experience less touching when he or she begins to let go.
Provide comfort measures including bath, massage, regulation of
environmental temperature, and mouth care according to patients
preferences. These measures promote relaxation and feelings of well
being.
Inform: Teach family members ways of discerning unobtrusively what
the patients desires for comfort and peace are at this time because some
patients prefer not to be bothered unless they specifically request comfort
measures. Being sensitive to patient needs promotes individualized care.
Teach caregivers to assist patient with self-care activities in a way
that maximizes patients rights to choose. This enables caregivers to
participate in patients care while supporting patients independence.
Attend: Help family identify, discuss, and resolve issues related to
patients dying. Provide emotional support and encouragement to
help. Clear communication promotes family integrity.
Demonstrate to patient willingness to discuss the spiritual aspects
of death and dying to foster an open discussion. Keep conversation
focused on patients spiritual values and the role they play coping
with dying. Meeting the patient's spiritual needs conveys respect for
the importance of all aspects of care.
If patient is confused, provide reassurance by telling him or her
who is in the room. This information may help to reduce anxiety.
Manage: Refer to hospice for end-of-life care if this has not already
been done. Communicate to the hospice nurse where the patient is
at present in coping with the terminal illness. Continuity of care is
crucial during times of stress.
Refer to a member of the clergy or a spiritual counselor, accord-
ing to the patients preference, to show respect for the patients
beliefs and provide spiritual care.
Active Listening; Anticipatory Guidance; Family Involvement Promo-
tion; Pain Management; Spiritual Support; Touch
Reference
Duggleby, W., & Berry, P. (2005, August). Transitions and shifting goals of
care for palliative patients and their families. Clinical Journal of Oncology
Nursing, 9(4), 425448.
RISK FOR ASPIRATION

DEFINITION
At risk for entry of gastrointestinal (GI) secretions, oropharyngeal
secretions, solids, or fluids into the tracheobronchial passages
RISK FACTORS
Decreased GI motility Medication administration
Delayed gastric emptying Reduced level of consciousness
Depressed cough and gag (LOC)
reflexes Situations hindering elevation
Feeding or GI tubes of upper body
Impaired swallowing Surgery or trauma to face,
Incompetent lower esophageal mouth, or neck
sphincter Tracheotomy or endotracheal
Increased gastric residual or tube
intragastric pressure Wired jaws
Elimination
Neurocognition
EXPECTED OUTCOMES
The patients will
Have clear breath sounds on auscultation.
Have normal bowel sounds.
Maintain patent airway.
Breathe easily, cough effectively, and show no signs of respiratory
distress or infection.
Demonstrate measures to prevent aspiration.
Maintain respiratory rate within normal limits for age.
Describe plan for home care.
Aspiration Prevention; Knowledge: Treatment Procedure(s); Respira-
tory Status: Ventilation; Risk Control; Swallowing Status
Determine: Assess for gag and swallowing reflexes. Impaired reflexes
may cause aspiration.
Assess respiratory status at least every 4 hr or according to estab-
lished standards; begin cardiopulmonary monitoring to detect signs
of possible aspiration (increased respiratory rate, cough, sputum pro-
duction, and diminished breath sounds).
Auscultate bowel sounds every 4 hr and report changes. Delayed
gastric emptying may cause regurgitation of stomach contents.
Elevate the head of the bed or place the patient in Fowlers posi-
tion to aid breathing.
21
Recognize the progression of airway compromise and report your
findings to detect complications early.
Perform: Help patient turn, cough, and deep breathe every 24 hr.
Perform postural drainage, percussion, and vibration every 4 hr, or
as ordered. Suction, as needed, to stimulate cough and clear upper
and lower airways. These measures promote drainage of secretions
and full expansion of lungs.
Perform chest physiotherapy before feeding to decrease the risk of
emesis leading to aspiration.
Elevate patient during feeding, and use an upright position after
feeding. Such positioning uses gravity to prevent regurgitation of
stomach contents and promotes lung expansion.
Place patient in the lateral or prone position and change position
at least every 2 hr to reduce the potential for aspiration by allowing
secretions to drain.
Inform: Instruct patient and family members in home care plan.
They must demonstrate the ability to carry out measures to prevent
or respond to aspiration events to ensure adequate home care before
discharge.
Attend: Encourage fluids within prescribed restrictions. Provide
humidification, as ordered (such as a nebulizer). Fluids and humidifi-
cation liquefy secretions.
Airway Management; Aspiration Precautions; Feeding; Positioning;
Respiratory Monitoring; Vital Signs Monitoring; Vomiting Manage-
ment
Reference
Thoyre, S. M., et al. (2005, MayJune). The early feeding skills assessment for
preterm infants. Neonatal Network, 24(3), 716.
RISK FOR IMPAIRED PARENTCHILD

ATTACHMENT
DEFINITION
Disruption of the interactive process between parent/significant other
and child/infant that fosters the development of a protective and
nurturing reciprocal relationship
RISK FACTORS
Anxiety over parental roles Inability of parents to meet
Illness in infant that doesnt their personal needs
allow initiation of interaction Lack of privacy, physical barri-
with parents ers, separation, substance abuse
Communication Role/relationships
Coping Sleep and rest
Emotional status Values and beliefs
EXPECTED OUTCOMES
The parents will
Initiate positive interaction with child.
Hold child and talk to him or her.
Express confidence in their ability to respond to childs needs.
Respond appropriately to child.
Express positive feelings about child.
Express confidence in their ability to care for child.
Recognize when they need assistance.
The child will
Respond positively to parents.
Show interest in parents faces.
Become calm when soothed by parents.
Parenting Performance; Role Performance
Determine: Assess composition of family and ages of members;
ability of family to meet physical and emotional needs of its mem-
bers; knowledge of growth and development patterns; energy levels
of parents; recent life changes; childs neurological and sensory
status, including vision and hearing; sleep patterns of parents and
child. This information will assist in establishing appropriate inter-
ventions.
Perform: Reduce environmental stressors (including people) where it
is possible to observe whether the parents responses to the child are
appropriate.
Provide parents and child with periods of privacy to promote
attachment.
23
Provide physical care to child when appropriate. This may be to
demonstrate to the family the appropriate way to perform ADLs.
Inform: Teach parents to observe and understand behavioral cues
from the child. For example, the child may become fussy when he
or she is ready for a nap or may pull his or her ear if he or she has
an earache. Explain the range of options for responding to these
cues positively. It is important that the parents have a variety of
options made available to them.
Teach parents to give physical care when the needs exist to
increase their self-confidence and self-competence.
Teach relaxation techniques (guided imagery, progressive muscle
relaxation, and meditation) that can be done by the parents to
restore psychological and physical equilibrium by decreasing
autonomic response to anxiety.
improve parents self-concept and self-confidence in parental roles.
Initiate discussions with parents on life changes precipitated by
the birth of the child. Parents are often confused and blame them-
selves because the stress of birth causes frustration and anger.
Encourage parents to talk about the kinds of activities that
promote feelings of comfort. Assist parents to create a plan to
engage in at least one of these activities each day. This provides par-
ents with a sense of control over their own lives.
Make sure parents have clear explanations for everything that is
expected of them. Ask for feedback to ensure parents understand.
Anxiety may impair their cognitive abilities.
Manage: Provide the name of professionals and/or agencies where
parents can receive assistance to continue developing attachment
skills and/or ongoing support. Refer to case manager/social worker
to assess the home environment to enable the parents to make mod-
ifications that will be needed.
Abuse Protection Support: Child; Child Coping Enhancement; Devel-
opmental Enhancement; Parenting
Reference
Delaney, K. R. (2006, November). Learning to observe relationships and cop-
ing. Journal of Child and Adolescent Psychiatric Nursing, 19(4), 194202.
AUTONOMIC DYSREFLEXIA
DEFINITION
Life-threatening, uninhibited sympathetic response of nervous system
to noxious stimulus after spinal cord injury at T7 or above
Paroxysmal hypertension (sud- Lack of caregiver and patient
den periodic elevated blood pres- knowledge
sure, systolic over 140 mm Hg Chilling
and diastolic over 90 mm Hg) Conjunctival congestion
Bradycardia or tachycardia Horners syndrome (contracted
(pulse less than 60 or more pupils, partial ptosis, enoph-
than 100 beats/min) Diaphore- thalmos, loss of sweating on
sis above injury affected side of face
Red splotches (vasodilation) [sometimes])
on skin above injury Paresthesia
Pallor below injury Pilomotor reflex
Diffuse headache not confined Blurred vision
to any nerve distribution area Chest pain
Bladder distention Metallic taste
Bowel distention Nasal congestion
RELATED FACTORS
Bladder distension Deficient patient knowledge
Bowel distension Skin irritation
Deficient caregiver knowledge
Cardiac function Neurocognition
Elimination Risk management
EXPECTED OUTCOMES
The patient will
Have cause of dysreflexia identified and corrected.
Experience cardiovascular stability as evidenced by ____ systolic
range, ____ diastolic range, and _____ heart rate range.
Avoid bladder distention and urinary tract infection (UTI).
Have no fecal impaction.
Have no noxious stimuli in environment.
State relief from symptoms of dysreflexia.
Have few, if any, complications.
Maintain normal bladder elimination pattern.
Maintain normal bowel elimination pattern.
Demonstrate knowledge and understanding of dysreflexia and will
describe care measures.
Experience few or no dysreflexic episodes.
25
Neurologic Status; Neurologic Status: Autonomic; Sensory Function
Status; Vital Signs Status
Determine: Assess for signs of dysreflexia (especially severe hyperten-
sion) to detect condition so that prompt treatment may be initiated.
Take vital signs frequently to monitor effectiveness of prescribed
medications.
Perform: Place patient in a sitting position or elevate the head of bed
to aid venous drainage from brain, lower intracranial pressure, and
temporarily reduce blood pressure.
Ascertain and correct probable cause of dysreflexia. Check for
bladder distention and patency of catheter. If necessary, irrigate
catheter with small amount of solution, or insert a new catheter
immediately. A blocked urinary catheter can trigger dysreflexia.
Check for fecal mass in rectum. Apply dibucaine ointment (Nuper-
cainal) or another product, as ordered, to anus and 1 (2.5 cms) into
rectum 1015 min before removing impaction. Failure to use
ointment may aggravate autonomic response.
Check environment for cold drafts and objects putting pressure on
patients skin, which could act as dysreflexia stimuli. Send urine for
culture if no other cause becomes apparent to detect possible UTI.
Implement and maintain bowel and bladder elimination programs
to avoid stimuli that could trigger dysreflexia
Inform: Instruct patient, family members, or caregiver about dysreflexia,
including its causes, signs and symptoms, and care measures to prepare
them to handle possible emergencies related to condition.
Attend: Reassure patient that everyone involved in his or her care
will be instructed in management of this problem to relieve anxiety.
Manage: If hypertension persists despite other measures, administer
ganglionic blocking agent, vasodilator, or other medication as ordered.
Drugs may be required if hypertension persists or if noxious stimuli
cant be removed.
Dysreflexia Management; Neurologic Monitoring; Surveillance; Tem-
perature Management; Vital Signs Monitoring
Reference
Karlsson, A. K. (2006). Autonomic dysfunction in spinal cord injury: Clinical
presentation of symptoms and signs. Progress in Brain Research, 152, 18.
RISK FOR AUTONOMIC DYSREFLEXIA

DEFINITION
At risk for life-threatening, uninhibited response of the sympathetic
nervous system, post spinal shock, in an individual with spinal cord
injury or lesion at T6 or above (has been demonstrated in patients with
injuries at T7 and T8)
RISK FACTORS
An injury or lesion at T6 or above and at least one of the following
noxious stimuli:
Cardiac/pulmonary problems Pressure over bony prominences
Deep vein thrombosis Pressure over genitalia
Pulmonary emboli Range of motion exercises
Gastrointestinal stimuli Spasm
Bowel distension Sunburns
Constipation or fecal Wounds
impaction Neurological stimuli
Digital stimulation Irritating stimuli below level
Enemas of injury
Esophageal reflux Regulatory stimuli
Gallstones Extreme environmental
Gastric ulcers temperatures
GI system pathology Temperature fluctuations
Musculoskeletalintegumentary Reproductive stimuli
stimulation Ejaculation
Cutaneous stimulation Labor and delivery
(e.g., pressure ulcer, ingrown Menstruation
toenail, dressings, burns, rash) Ovarian cyst
Fractures Pregnancy
Heterotrophic bone Sexual intercourse
EXPECTED OUTCOMES
The patient will
Identify and reduce risk factors for dysreflexia.
Avoid bladder distention.
Will not experience a UTI.
Maintain normal urinary and bowel elimination patterns.
Be free from fecal impaction.
Have an environment free from noxious stimuli that may cause
dysreflexia.
Express understanding of causes of dysreflexia.
Demonstrate understanding of measures to prevent dysreflexia.
27
Neurologic Status: Autonomic; Symptom Severity; Vital Signs Status
Determine: Assess for risk factors of dysreflexia, such as
constipation, fecal impaction, distended bladder, and presence of
noxious stimuli. Identifying risk factors can prevent or minimize
dysreflexic episodes.
Monitor and record intake and output accurately to ensure ade-
quate fluid replacement, thereby helping to prevent constipation.
Monitor vital signs frequently to ensure effectiveness of preventive
measures. Severe hypertension may indicate dysreflexia.
Perform: Check for bladder distention and patency of catheter. A
blocked catheter can trigger dysreflexia.
Check for abdominal distention and assess bowel sounds. Monitor
and record characteristics and frequency of stools. Fecal impaction
may lead to dysreflexia.
Administer laxative, enema, or suppositories, as prescribed, to
promote elimination of solids and gases from GI tract. Monitor
effectiveness.
Implement and maintain bowel and bladder programs to avoid
stimuli that could trigger dysreflexia.
Inform: Instruct patient, family member, or caregiver about risk fac-
tors, signs and symptoms, and care measures for dysreflexia to help
prevent a possible dysreflexic episode and help him or her respond
appropriately should dysreflexia occur.
Attend: Encourage fluid intake of 212 qt (2.5 L) daily, unless
contraindicated. Adequate fluid intake helps maintain patency of
catheter and aids bowel elimination.
Manage: Consult with dietitian about increasing fiber and bulk in
diet to maximum prescribed by physician to improve intestinal mus-
cle tone and promote comfortable elimination.
Dysreflexia Management; Neurologic Monitoring; Vital Signs Moni-
toring
Reference
Joseph, A. C., & Albo, M. (2004, October). Urodynamics: The incidence of
urinary tract infection and autonomic dysreflexia in a challenging popula-
tion. Urologic Nursing, 24(5), 390393.
RISK-PRONE HEALTH BEHAVIOR

DEFINITION
Impaired ability to modify lifestyle/behaviors in a manner consistent
with a change in health status
Demonstration of nonacceptance of health status to achieve opti-
mal sense of control
Failure to take action to prevent future health problems
Denial of health status change
RELATED FACTORS Low self-efficacy
Inadequate comprehension Multiple stressors
Inadequate social support
Negative attitude toward healthcare
Behavior Knowledge
Coping
EXPECTED OUTCOMES
The patient will
Identify inability to cope and will adjust adequately.
Express understanding of the illness or disease.
Participate in healthcare regimen including planning activities.
Demonstrate ability to manage health problems.
Help perform self-care activities.
Show ability to accept and adapt to a new health status and inte-
grate learning.
Demonstrate new coping abilities.
Acceptance: Health Status; Adaptation to Physical Disability; Cop-
ing; Health Seeking Behavior; Participation in Healthcare Decisions;
Psychosocial Adjustment: Life Change; Social Support; Treatment
Behavior: Illness
Determine: Assess patients present understanding of health status
and treatment to form the basis for any further planning. Assess
feelings about present health status. Do this in a safe, nonthreaten-
ing environment to allow the patient to gain insight into and ration-
ally define fears, goals, and potential problems. Monitor patient
involvement in care-related activities.
Perform: Make changes in the environment that will encourage
healthy behavior.
29
Inform: Teach patient and caregiver the skills necessary to manage
care adequately. Teaching will encourage compliance and adjustment
to optimum wellness.
Teach patient how to find areas in which it is possible to maintain
control to avoid feelings of powerlessness and allow the patient to
feel like a member of the teams effort to assist him or her.
that maximizes patients potential. This enables caregivers to partici-
pate in patients care and encourages them to support patients inde-
pendence.
Attend: Provide emotional support and encouragement by listening
to the patients feelings. This will reassure the patient that you care.
Allow patient to grieve. Grieving is a normal and essential aspect
of any kind of negative change in health status. After working
through denial and isolation, anger, bargaining, and depression, the
patient will progress toward acceptance.
Provide reassurance that the patients feelings, under the circum-
stances, are normal. By realizing that it is acceptable to grieve, the
patient will be willing to look for positive ways of coping.
for activity.
Discuss health problems with family members to encourage partic-
ipation in the patients care.
Manage: Refer to a mental health specialist if patient develops severe
depression or other psychiatric problem. Although trauma or illness
commonly causes some depression or other psychiatric disorders,
consultation with a mental health professional may help minimize it.
Arrange for an individual who has the same problem to meet
with the patient. This exposes the patient to suitable role models
and may encourage a supportive relationship to evolve.
Anxiety Reduction; Behavior Modification; Coping; Enhancement;
Counseling; Decision-Making Support; Mutual Goal-Setting; Role
Enhancement; Support System Enhancement
Reference
Telford, K., et al. (2006, August). Acceptance and denial: Implications for
people adapting to chronic illness: Literature review. Journal of Advanced
Nursing, 55(4), 457464.
RISK FOR BLEEDING

DEFINITION
At risk for a decrease in blood volume that may compromise health
RISK FACTORS
Pregnancy-related Circumcision
complications (e.g., placenta Disseminated intravascular
praevia or abruptio) coagulopathy
Postpartum complications (e.g., Inherent coagulopathies (throm-
uterine atony, retained placenta) bocytopenia, hemophilia)
Treatment-related side effects GI disorders (e.g., gastric
(e.g., surgery, medications ulcers, polyps, varices)
affecting the bleeding and Aneurysm
clotting, administration of Impaired liver function (e.g.,
platelet-deficient blood prod- cirrhosis, hepatitis)
ucts, chemotherapy) Trauma or history of falls
Cardiac function Reproduction
Fluid and electrolytes Tissue perfusion
Pharmacologic function/treatments
EXPECTED OUTCOMES
The patient will
Receive screening to alert about existing risk factors for bleeding.
Receive follow-through intervention.
Receive appropriate clinician staffing and surveillance for a rapid
response to rescue the patient before serious bleeding occurs.
Maintain heart rate, rhythm, blood pressure, and tissue perfusion
within expected ranges during episodes of risk.
Identify and avoid risk situations with potential for trauma injury.
Maternal Status: Antepartum; Postpartum; Blood Coagulation; Blood
Loss Severity; Circulation Status; Vital Sign; Fluid Balance;
Electrolyte & Acid Base Balance; Tissue Perfusion: Cellular
Determine: Interview/screen each individual for risk factors for bleed-
ing; some individuals know of their risks for bleeding, whereas others
do not. Assessment findings may indicate need for protective measures.
Anticipate conditions and episodes of care that may precipitate
bleeding especially in high-risk patient care areas to provide early
intervention. Monitor physiologic responses for values that exceed
expected or normal ranges; early bleeding compensatory mechanisms
alter respirations, pulse, and blood pressure and may be present as
subtle changes. Monitor for occult and for frank bleedingurine,
feces, wounds, and dressingsby visual inspection or point-of-care
testing to identify need for intervention.
31
Perform: Correlate findings, risk factors, and current episode of care and
patient condition to determine the imminent level of risk for bleeding.
Perform vital signs and basic physical assessments for the patient
who is at risk for bleeding until assured the risk is past to provide
data needed for early intervention. Obtain laboratory tests
(hemoglobin, hematocrit, complete blood cell count, thrombin time,
prothrombin time, activated partial thromboplastin time, etc.) and
point-of-care tests (stool, urine, gastric); these tests provide data that
may be indications of a bleed.
Examine dressings, drainage tubes, and collection canisters for pres-
ence of blood; report findings to support need for changes in therapy.
Inform: Teach patient about intended and unintended effects of med-
ications (heparin, enoxaparin [Lovenox], warfarin (Coumadin), clopi-
dogrel [Plavix], aspirin) that increase the risk of bleeding or prolong
clotting. This enables the patient to avoid bleeding-risk situations.
Discuss patterns of risk management to promote a lifestyle that
focuses on health promotion/injury avoidance to diminish injuries.
Discuss alternatives in ADLs to avoid trauma-causing injury and
bleeding.
Attend: Provide care protecting an individual from injury to prevent
bleeding. Implement interventions that reverse or remove the risk of
bleeding or bleeding condition to prevent bleeding or stabilize the
patients physiologic condition and assist in recovery.
Provide emotional support to the patient who is bleeding and is
experiencing physiologic compensatory responses of anxiety, fear, and
a sense of dread as this support provides assurance and is calming.
Support participation in decisions about the treatment placing the
patient at risk for bleeding. Active participation encourages fuller
understanding of the rationale and compliance with the treatment.
Manage: Refer to case manager or APN those at risk for bleeding
secondary to treatment (i.e., warfarin INR) for monitoring and
regime adherence. Monitor the recovery of the individual who expe-
rienced a bleeding episode because weakness causes a safety risk for
falls or injury.
Bleeding Precautions; Bleeding Reduction Uterus, Gastrointestinal;
Blood Products Administration; Circulatory Precautions; Fluid/Elec-
trolyte Management; Risk Identification; Teaching Prescribed Med-
ications; Vital Sign Monitoring
References
Fishbach, F., & Dunning, M. B. (2009). A manual of laboratory & diagnostic
tests (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
McCance, K., & Huether, S. (2006). Pathophysiology: The biologic basis for
disease in adults and children (5th ed.). St. Louis, MO: Mosby.
DISTURBED BODY IMAGE

DEFINITION
Confusion in mental picture of ones physical self
Physiologic changes, behavioral changes, usual patterns of coping
with stress
Missing body part, not looking or touching a body part, negative
feelings about a body part
Frequent or disparaging comments about aging and its physical
manifestations
Personal rigidity or unwillingness to change
Actual change in structure or function
Change in social relationships
Hiding or overexposing of a body part (intentional or
unintentional)
Depersonalization of loss by using third person pronouns
Unintentional or intentional overexposing of body part
RELATED FACTORS
Biophysical Illness
Cognitive Surgery
Cultural Trauma
Behavior Sexuality
Knowledge Values/beliefs
Sensory perception
EXPECTED OUTCOMES
The patient will
Identify physical changes without making disparaging comments.
Identify at least one positive aspect of aging.
Use vision or hearing aids appropriately.
Demonstrate increased flexibility and willingness to consider
lifestyles changes.
Participate in at least one social activity regularly.
Exercise and engage in other physical activity at level consistent
with desire, ability, and safety.
Body Image; Grief Resolution; Self-Esteem
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure.
Assess understanding of the current health problem and desire to
33
participate in treatment. Assessment information is helpful in deter-
mining appropriate interventions.
Perform: Perform ADL measures that the patient is unable to
perform for self while promoting as much independence as possible.
Inform: Provide patient with information on appropriate self-care
activities (e.g., maintaining proper diet; bathing as needed; using
alcohol-free skin lotions to combat dryness; exercising appropriately
to maintain muscle mass, bone strength, and cardiorespiratory
health; avoiding fractures related to osteoporosis) to ensure that the
patient will be able to perform self-care measures.
Teach patient about isometric exercises to maintain or increase
muscle tone and joint mobility.
pate in patients care while supporting patients independence.
patients self-concept and promote motivation to perform ADLs.
Assist patient to learn how to perform self-care activities. Begin
slowly and increase daily, as tolerated. Performing self-care activities
will assist patient to regain independence and enhance self-esteem.
Involve patient in planning and decision making. Having the ability
to participate will encourage greater compliance with the plan for
activity.
Focus on patients strengths and what the patient is able to do for
self.
Encourage patient to engage in social activities with people of all
age groups. Participation once a week will help relieve patients
sense of isolation.
Manage: Refer to case manager/social worker to ensure patient
receives long-term assistance with body image problem.
Refer patient to a support group. In the context of a group, the
patient may develop a more positive view of present situation.
Refer for corrective eyewear and hearing aids to address sensory
deficits.
Active Listening; Body Image Enhancement; Grief Work Facilitation;
Self-Esteem Enhancement
Reference
Barba, B. E., & Colemen, P. (2006, August). What are old people for? Journal
of Gerontological Nursing, 32(8), 78.
RISK FOR IMBALANCED BODY TEMPERATURE

DEFINITION
At risk for failure to maintain body temperature within normal
range
RISK FACTORS
Altered metabolic rate Illness/trauma affecting
Dehydration temperature regulation
Exposure to extreme hot/cold Medications causing vasocon-
environments striction
Advanced age Inactivity/vigorous activity
Extremes of weight
Fluid and electrolytes Nutrition
Neurocognition Respiratory function
EXPECTED OUTCOMES
The patient will
Maintain body temperature of 98.6 F99.5 F (37 C37.5 C).
Maintain weight within 5% of baseline.
Maintain balanced intake and output within normal limits for age.
Have a urine-specific gravity between 1.010 and 1.015.
Hydration; Medication Response; Thermoregulation
Determine: Assess temperature every 4 hr. Use a temperature-taking
method appropriate for age and size (rectal or axillary for an infant
or toddler, axillary or oral for a preschooler, and oral for a school-
aged child or adult). Prolonged elevation of temperature above 104 F
(40 C) may produce dehydration and harmful central nervous system
effects.
Weigh patient every morning and record results. A decrease in
weight may indicate dehydration.
Assess the patients knowledge and lifestyle before teaching about
hypothermia and hyperthermia to gear the teaching plan to the
patients needs.
Perform: Maintain adequate fluid intake by offering small amounts
of flavored fluids at frequent intervals; record intake and output
every shift. Fever increases fluid requirements by increasing the
metabolic rate. Provide high-calorie liquids, such as colas, fruit
juices, and flavored water sweetened with corn syrup, to help
prevent dehydration.
Administer antipyretics, as ordered, and monitor effectiveness.
Antipyretics act on the hypothalamus to regulate body temperature.
35
Check and record urine-specific gravity with each voiding. Urine-
specific gravity increases with dehydration. Adequate urine output
and urine-specific gravity between 1.010 and 1.015 indicate
sufficient hydration.
Give a tepid sponge bath for increased temperature to increase
vaporization from skin and decrease body temperature.
Inform: Teach patient to dress in lightweight clothing when experi-
encing elevated body temperature to allow perspiration to evaporate,
thereby releasing body heat.
Instruct the patient on the signs and symptoms of imbalanced
body temperature:
Hypothermia: shallow respirations; slow, weak pulse; decreased
body temperature; low blood pressure; and pallor
Hyperthermia: shivering, shaking chill; feeling hot; extreme
thirst; elevated body temperature; and high blood pressure.
Listing the signs and symptoms helps the patient learn and iden-
tify warning signals of imbalanced body temperature. Large black
type is easier for the older patient to read.
Explain to the patient or family member why the patient needs
warm clothing in cool climates, even indoors. Suggest socks, nonslip
house shoes, and leg warmers to provide warmth to vulnerable
lower extremities, where vascular changes may cause decreased tem-
perature sensation.
Instruct the patient or family member to label home thermostats
with large numbers and to use black or bright contrasting colors to
indicate appropriate temperature settings. Easy-to-read labels will
help the patient maintain room temperature.
Teach the patient or his or her family members about the dangers
of too much direct sunlight on warm days to prevent overheating in
an older patient with faulty thermoreceptors.
Attend: Encourage the patient to remain active when in a cool envi-
ronment to keep warm and maintain normal metabolism.
Manage: Suggest that a friend, family member, or volunteer from a
local community organization visit the patient daily to help ensure
the patients safety.
Fever Treatment; Medication Management; Temperature Regulation;
Vital Signs Monitoring
Reference
Braun, C. A. (2006, SeptemberOctober). Accuracy of pacifier thermometers
in young children. Pediatric Nursing, 32(5), 413418.
BOWEL INCONTINENCE
DEFINITION
Change in normal bowel habits characterized by involuntary passage
of stool
Constant dribbling of soft stool
Fecal odor
Fecal staining of clothing or bedding
Inability to delay defecation
Inability to recognize urge to defecate
Recognizes rectal fullness but reports inability to expel formed stool
Inattention to urge to defecate
Self-report of inability to recognize rectal fullness
Red perianal skin
Urgency
RELATED FACTORS
Abnormally high abdominal Impaired reservoir capacity
pressure Incomplete emptying of bowel
Abnormally high intestinal Laxative abuse
pressure Loss of rectal sphincter
Chronic diarrhea control
Colorectal lesions Lower motor nerve damage
Dietary habits Medications
Environmental factors (e.g., Rectal sphinter abnormality
inaccessible bathroom) Impaction
General decline in muscle tone Stress
Immobility Toileting self-care deficit
Impaired cognition Upper motor nerve damage
Fluid and electrolytes
Elimination
Neurocognition
EXPECTED OUTCOMES
The patient will
Experience a bowel movement every ___ day(s) when placed on
commode or toilet at ___ AM/PM.
Maintain clean and intact skin.
Have improved control of incontinent episodes.
State understanding of bowel routine.
Demonstrate skill in using commode.
Demonstrate skill in the use of suppository if indicated.
Express an understanding of the relationship between food and
fluid regulation and the promotion of continence.
37
Maintain self-respect and dignity through participation and accept-
ance within group.
Bowel Continence; Bowel Elimination; Self-Care: Toileting
Determine: Establish a regular pattern for bowel care; for example,
after breakfast every other day, place patient on the commode chair
1 hr after inserting suppository, allow patient to remain upright for
30 min for maximum response, and then clean the anal area. Proce-
dure encourages adaptation and routine physiologic function.
Monitor and record incontinent episodes; keep baseline record for
37 days to track effectiveness of toileting routine.
Perform: Clean and dry perianal area after each incontinent episode
to prevent infection and promote comfort.
Inform: Demonstrate bowel care routine to family or caregiver to
reduce anxiety from lack of knowledge or involvement in care.
Arrange for return demonstration of bowel care routine to help
establish therapeutic relationship with patient and family or
caregiver.
Establish a date when family or caregiver will carry out bowel
care routine with supportive assistance; this will ensure that patient
receives dependable care.
Discuss bowel care routine with family or caregiver to foster com-
pliance.
Instruct family or caregiver on need to regulate foods and fluids
that cause diarrhea or constipation to encourage helpful nutritional
habits.
Attend: Maintain patients dignity by using protective padding under
clothing, by removing patient from group activity after incontinent
episode, and by cleaning and returning patient to the group without
undue attention. These measures prevent odor, skin breakdown, and
embarrassment and promote patients positive self-image.
Manage: Maintain diet log to identify irritating foods, and then
eliminate them from patients diet.
Bowel Incontinence Care; Bowel Management; Perineal Care; Skin
Surveillance
Reference
Dowd, T., & Dowd, E. T. (2006, JanuaryFebruary). A cognitive therapy
approach to promote continence. Journal of Wound, Ostomy and
Continence Nursing, 33(1), 6368.
EFFECTIVE BREASTFEEDING
DEFINITION
Mother-infant dyad/family exhibits adequate proficiency and satisfac-
tion with breastfeeding process
Ability to promote successful latching on through correct position-
ing (mother)
Adequate elimination pattern for age (infant)
Appropriate weight pattern for age (infant)
Eagerness to nurse (infant)
Effective communication pattern (mother and infant)
Evidence of contentment after feeding
Expressed satisfaction with breastfeeding (infant)
Regular and sustained sucking and swallowing at breast (infant)
Signs and symptoms of oxytocin release (mother)
RELATED FACTORS
Basic breastfeeding knowledge Normal breast structure
Infant gestational age 34 Support source
weeks
Coping Nutrition
Growth and development Values and beliefs
Knowledge
EXPECTED OUTCOMES
The mother will
Breast-feed infant successfully and will experience satisfaction with
breastfeeding process.
Continue breastfeeding infant after early postpartum period.
The infant will
Feed successfully on both breasts and appear satisfied.
Grow and develop in pace with accepted standards.
Breastfeeding Establishment: Infant; Breastfeeding Establishment:
Maternal; Breastfeeding Maintenance; Breastfeeding: Weaning;
Hydration; Knowledge: Breastfeeding
Determine: Assess mothers knowledge and experience with
breastfeeding to focus teaching on specific learning needs.
Assess mothers attitudes and beliefs about breastfeeding to help
plan for interventions.
Monitor height and weight of infant to ensure infant meets the
standards for breastfeeding.
Perform: Weigh and measure the infant. Provide a quiet and private
environment to enhance the development of breastfeeding skills.
39
Inform: Educate mother and selected support person about
breastfeeding techniques to improve chance of success. Have the
mother perform return demonstration of techniques as appropriate:
Clean hands and breasts before nursing.
Position infant for feeding (infant should be able to grasp most of
the areola).
Change positions to decrease nipple tenderness and use both
breasts at each feeding.
Remove infant from the breast by breaking suction; avoid setting
time limits in the early stage.
After breastfeeding, place clean pads on breasts.
Teach mother how to use warm showers and compresses, relaxation
and guided imagery, infant suckling, holding the infant close to the
breasts, and listening to the infant cry in order to stimulate letdown.
Teach mother about nutritional needs including an extra 500 calories
and two additional 8-oz glasses of fluid per day to maintain adequate
milk supply and to limit caffeine and food that causes discomfort.
pate in patients care and encourages them to support patients inde-
pendence.
Teach mother what to expect from a breastfeeding infant to prepare
her for breastfeeding at home. The infant should pass from 1 to 6
stools and wet 68 diapers per day. Stools should be soft to liquid and
nonodorous. Infant should feed every 23 hr or as needed and appear
content. Explain that the infant also needs nonnutritive sucking.
Getting an upset neonate to breast-feed can be extremely difficult.
Attend: Encourage mother to express concerns about breastfeeding
to reduce anxiety. Assist the mother and family in planning for
home care. The mother needs to rest when the infant sleeps, practice
self-care, learn techniques for expressing and storing breast milk,
and recognize signs of engorgement and infection. A mother who
stops breastfeeding when she returns home and resumes work usu-
ally does so because of fatigue.
Manage: Refer patient to support group for breastfeeding mothers to
help meet emotional and learning needs.
Breastfeeding Assistance; Family Support; Lactation Counseling;
Nutritional Management; Parent Education: Infant
Reference
Noel-Weiss, J., et al. (2006, MayJune). Developing a pre-natal breastfeeding
workshop to support maternal breastfeeding self-efficacy. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 35(3), 349357.
INEFFECTIVE BREASTFEEDING
DEFINITION
Dissatisfaction or difficulty a mother, infant, or child experiences
with the breastfeeding process
Actual or perceived inadequate milk supply (mother)
Arching and crying when at the breast (infant)
Evidence of inadequate intake (infant)
Fussiness and crying within the first hour of feeding (infant)
Inability to latch on to nipple correctly (infant)
Insufficient emptying of each breast
Unsatisfactory breastfeeding process (mother and infant)
RELATED FACTORS
Infant anomaly Maternal ambivalence
Infant receiving supplemental Maternal anxiety
feeding with artificial nipple Nonsupportive family
Knowledge deficit Nonsupportive partner
Communication
Roles and relationships
Values and beliefs
EXPECTED OUTCOMES
The mother will
Express physical and psychological comfort in breastfeeding prac-
tice and techniques.
Show decreased anxiety and apprehension.
State at least one resource for breastfeeding support.
The infant will
Feed successfully on both breasts and appear satisfied for at least
2 hr after feeding.
Grow and thrive.
Breastfeeding Assistance; Emotional Support; Lactation Counseling;
Nutritional Management; Parent Education; Support Group
Determine: Assess factors that influence mothers decision to breast-
feed. Assessment information will be used to develop interventions.
Monitor condition of breasts and nipples to identify problems that
might interfere with feeding to pinpoint problem areas.
Assess readiness of mother to breast-feed and ability of infant to
feed.
Monitor mothers breastfeeding technique. Improper technique,
which impedes feeding, will cause the mother to experience anxiety.
41
Perform: Position mother in Fowlers position to enhance mothers
relaxation during feeding. Place infant in proper position for optimal
feeding to produce proper sucking motion.
Inform: Teach mother and selected caregiver the techniques for
encouraging letdown, including warm shower, breast massage, physi-
cally caring for the neonate, and holding the neonate close to the
breasts.
Teach mother techniques (e.g., lying on her side, positioning the
infant correctly, holding the nipple with C position, talking to and
cuddling the infant) that will help the infant latch on to the breast.
Instruct mother to remove infant from the breast to be burped
midway during the feeding to allow for expulsion of air that is
swallowed.
Attend: Ask frequently during hospitalization whether the mother
has questions while she is attempting to breast-feed. This will give
her the confidence she needs to continue when she gets home.
Provide mother and infant with a quiet, private, comfortable envi-
ronment in which to breast-feed. Decreasing stressors will help to
promote successful breastfeeding experience.
Encourage expression of fears and anxieties between the mother
and the infant to reduce anxiety and increase the mothers sense of
control over the process.
Manage: Offer written information, a reading list, or a referral to a
breastfeeding support group to allow for review of information after
discharge:
Refer to home health nurse for a follow-up visit in the home.
Refer to a nutritionist for information on good nutrition and fluid
management.
Breastfeeding Assistance; Emotional Support; Lactation Counseling;
Infant; Parent Education; Support Group
Reference
Lewallen, I. P., et al. (2006, August). Toward a clinically useful method of
predicting early breastfeeding attrition. Applied Nursing Research, 19(3),
144148.
INTERRUPTED BREASTFEEDING
DEFINITION
Break in continuity of the breastfeeding process as a result of
inability or inadvisability to put baby to breast for feeding
Continued desire to maintain lactation and provide breast milk for
infants nutritional needs (mother)
Failure to receive nourishment at breast for some or all feedings
(infant)
Lack of knowledge about expressing or storing milk (mother)
Separation of mother and infant
RELATED FACTORS
Contraindications to Maternal illness
breastfeeding Need to wean infant abruptly
Infant illness Prematurity
Maternal employment
Coping Knowledge
Communication Values and beliefs
EXPECTED OUTCOMES
The mother will
Express her understanding of factors that necessitate interruption
in breastfeeding.
Express comfort with her decision about whether to resume
breastfeeding.
Express and store breast milk appropriately.
Resume breastfeeding when the interfering factor ceases.
Have adequate milk supply when breastfeeding resumes.
Obtain relief from discomfort associated with engorgement.
Ensure that infants nutritional needs are met.
Breastfeeding Maintenance; Knowledge: Breastfeeding; Motivation;
ParentInfant Attachment; Parenting Performance; Role Performance
Determine: Assess mothers understanding for interrupting breastfeeding
to evaluate need for further instruction.
Assess mothers desire to resume breastfeeding when reasons for
interruption are no longer a factor. The mother may not wish to
continue breastfeeding.
Assess mothers emotional reactions to having to interrupt breastfeed-
ing. Emotional feelings may affect resumption after interruption.
Perform: Review mothers daily routine to advise her how to incor-
porate breastfeeding into her schedule. Mother must have a plan in
43
order to carry on usual routine and still make sure the baby is fed
on schedule.
Inform: Instruct mother in methods for expressing and storing breast
milk. Demonstrate the use of a breast pump utilizing the following
guidelines:
Initiate pumping 2448 hr after delivery.
Pump a minimum of 5 times a day.
Pump a minimum of 100 min a day.
Pump long enough to soften breasts each time regardless of
duration.
Instruct mother in ways to prevent breast engorgement to prevent
discomfort that may keep infant from sucking effectively. Teach the
mother about the use of nipple shield (if appropriate). The shield is
designed to alter flat or inverted nipples.
improve patients confidence and motivation to resume breastfeeding
when possible.
Reassure mother that infants nutritional needs will be met
through other methods to allay her anxiety.
If mother must pump for a prolonged period, encourage her to
use a piston-style electric pump. Using an electric pump rather than
a hand pump produces milk with a higher fat content.
ity to participate will encourage greater compliance with the plan to
resume breastfeeding.
If mother chooses not to resume breastfeeding, advise her to wear
a supportive bra, apply ice, and take a mild analgesic to alleviate
discomfort associated with engorgement.
Manage: Refer to a lactation support group for continued assistance
in resuming breastfeeding after an interruption.
Provide appropriate educational home assessment. If possible,
have a home health nurse visit the mother and infant to assess
progress.
Attachment Promotion; Bottle Feeding; Emotional Support; Infant;
Lactation Counseling; Parent Education; Teaching: Individual
Reference
Spatz, D. L. (2006, JanuaryMarch). State of the science: Use of human milk
and breastfeeding for vulnerable infants. The Journal of Perinatal &
Neonatal Nursing, 20(1), 5155.
INEFFECTIVE BREATHING PATTERN

DEFINITION
Inspiration and/or expiration that does not provide adequate ventilation
Accessory muscle use
Abnormal heart rate response to activity
Altered respiratory rate or depth or both
Assumption of 3-point position
Decreased minute ventilation
Decreased vital capacity
Decreased tidal volume
Dyspnea
Nasal flaring
Prolonged expiratory phase
Pursed lip breathing
RELATED FACTORS
Anxiety Obesity
Body position Pain
Chest wall deformity Respiratory muscle fatigue
Musculoskeletal impairment
Activity/exercise Neurologic and mental status
Cardiac function Respiratory function
EXPECTED OUTCOMES
The patient will
Maintain respiratory rate within 5 of baseline.
Regain arterial blood gases to baseline.
Express feelings of comfort when breathing.
Demonstrate diaphragmatic pursed-lipped breathing.
Achieve maximal lung expansion with adequate ventilation.
Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
Demonstrate skill in conserving energy while carrying out ADLs.
Mechanical Ventilation Response: Adult; Respiratory Status: Airway
Patency; Respiratory Status: Gas Exchange; ADLs
Determine: Monitor and record respiratory rate and depth at least
every 4 hr to detect early stages of respiratory failure. Auscultate
breath sounds at least every 4 hr to detect decreased or adventitious
breath sounds. Report changes.
Perform: Administer oxygen, as ordered, to maintain an acceptable
level of oxygen at the tissue level.
Suction airway as needed to maintain patent airways.
45
Assist patient to Fowlers position, which will promote expansion
of lungs and provide comfort. Support upper extremities with
pillows, providing a table and cover it with a pillow to lean on.
Assist patient with ADLs as needed to conserve energy and avoid
overexertion.
Encourage active exercise: Provide a trapeze or other assistive device
whenever possible. Such devices simplify moving and turning for many
patients and allow them to strengthen some upper body muscles.
Inform: Teach patient the following measures to promote participa-
tion in maintaining health status and improve ventilation: pursed lip
breathing, abdominal breathing, and relaxation techniques (deep
breathing, meditation, guided imagery), taking prescribed
medications (ensuring accuracy and frequency and monitoring side
effects); and scheduling of activities to allow for rest periods.
Teach caregivers to assist patient with ADLs in a way that maxi-
mizes patients potential. This enables caregivers to participate in
patients care and encourages them to support patients independence.
patients self-concept and motivate patient to perform ADLs.
Involve patient in planning and decision making. Having the ability to
participate will encourage greater compliance with the plan for activity.
Have patient perform self-care activities. Begin slowly and increase
daily, as tolerated. Performing self-care activities will assist patient
to regain independence and enhance self-esteem.
Schedule activities to allow for periods of rest.
assessment has been done and that whatever modifications were
needed to accommodate the patients level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
Refer patient for evaluation of exercise potential and development
of individualized exercise program. Gradual increase in exercise will
promote conditioning and ease breathing.
Airway Management; Anxiety Reduction; Oxygen therapy; Progres-
sive Muscle Relaxation; Respiratory Monitoring
Reference
Booker, R. (2005, January). Chronic obstructive pulmonary disease: Nonphar-
macological approaches. British Journal of Nursing, 14(1), 1418.
DECREASED CARDIAC OUTPUT

DEFINITION
Inadequate blood pumped by the heart to meet metabolic demands
of the body
Altered heart rate and rhythm
Abnormal heart rate response to activity
Arrhythmias, palpitations, electrocardiographic changes
Abnormal chest x-rays and cardiac enzymes
Electrocardiographic changes reflecting ischemia
Exertional discomfort
Exertional dyspnea
Verbal report of fatigue
Verbal report of weakness
Crackles
Cough
Anxiety/restlessness
RELATED FACTORS
Altered afterload Altered heart rhythm
Altered contractility Altered preload
Altered heart rate Altered stroke volume
Cardiac function Activity/exercise
Respiratory function Fluid and electrolytes
EXPECTED OUTCOMES
The patient will
Maintain pulse within predetermined limits.
Maintain blood pressure within predetermined limits.
Exhibit no arrhythmias.
Maintain warm and dry skin.
Exhibit no pedal edema.
Maintain acceptable cardiac output.
Verbalize understanding of reportable signs and symptoms.
Understand diet, medication regimen, and prescribed activity level.
Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion:
Peripheral; Vital Signs
Determine: Monitor patient at least every 4 hr for irregularities in
heart rate, rhythm, dyspnea, fatigue, crackles in lungs, jugular venous
distension, or chest pain. Any or all of these may indicate impending
cardiac failure or other complications. Report changes immediately.
Perform: Administer oxygen as ordered to increase supply to
myocardium.
47
Administer antiarrhythmic drugs, as ordered, to reduce or elimi-
nate rhythm disturbances. Monitor for adverse effects.
Administer stool softeners, as prescribed, to reduce straining dur-
ing bowel movements.
Measure and record intake and output. Decreased urinary output
without decreased fluid intake may indicate decreased renal
perfusion resulting from decreased cardiac output.
Weigh patient daily before breakfast to detect fluid retention.
Perform active or passive ROM exercises to all extremities every
24 hr. ROM exercises foster muscle strength and tone, maintain
joint mobility, and prevent contractures.
Inspect legs and feet for pedal edema.
Maintain dietary restrictions, as ordered, to prevent fluid
retention, dehydration, weight gain or loss.
Gradually increase levels of activity within prescribed limits of
cardiac rate to allow heart to adjust to increased cardiac demands.
Inform: Educate patient and his or her family about chest pain and
other reportable symptoms, prescribed diet, medications (name,
dosage, frequency, and therapeutic and adverse effects), prescribed
activity level, simple methods of lifting and bending, and stress-
reduction techniques. Education promotes remembering of and com-
pliance with techniques to reduce energy consumption.
improve patients self-concept.
Involve patient in planning and decision making. Having the ability to
participate will encourage greater compliance with the plan of treatment.
assessment has been done and that whatever modifications are
needed to accommodate the patients ongoing care have been made.
Refer to cardiac program for exercise when the time is appropriate.
Cardiac Precautions; Circulatory Precautions; Fluid Management;
Homodynamic Regulation; Vital Signs Monitoring
Reference
Kodiath, K., et al. (2005). Improving quality of life in patients with heart failure:
An innovative behavioral intervention. Journal of Cardiovascular Nursing,
20(1), 4348.
LWBK392-c02_p48-93.qxd 17/11/2009 09:31 AM Page 48 Aptara
CAREGIVER ROLE STRAIN

DEFINITION
Difficulty in performing a family caregiver role
Difficulty performing/completing required tasks
Preoccupation with care routine
Apprehension about care receivers health and caregivers ability to
provide care
Fate of the care receiver if the caregiver becomes ill or dies, or the
possible institutionalization of care receiver
Caregivercare receiver relationship: grief or uncertainty regarding
changed relationship with care receiver
Difficulty with watching care receiver experience the illness
RELATED FACTORS
Care receiver health status Caregiving activities
Caregiver health status Family processes
Caregivercare receiver Resources
relationship Socioeconomic
Behavior Neurocognition
Coping Role/relationships
Emotional Support systems
Home environment
EXPECTED OUTCOMES
The caregiver will
Describe current stressors.
Identify stressors that can and cant be controlled.
Identify formal and informal sources of support.
Show evidence of using support systems.
Report increased ability to cope with stress.
Caregiver Emotional Health; Caregiver Lifestyle Disruption;
Caregiver Stressors; Caregiver Well-Being; Caregiving Endurance
Potential
Determine: Help caregivers identify current stressors to evaluate the
causes of role strain.
Perform: Provide care, as indicated, to give caregivers respite.
Inform: Suggest ways for caregivers to use time more efficiently. For
example, caregiver may save time by filling out insurance forms
while visiting and chatting with care recipient. Better time manage-
ment may help caregiver reduce stress.
49
Attend: Using a nonjudgmental approach, help caregiver evaluate
which stressors are controllable and which arent to begin to
develop strategies to reduce stress.
Encourage caregiver to discuss coping skills used to overcome sim-
ilar stressful situations in the past to build confidence for managing
the current situation.
Encourage caregiver to participate in a support group. Provide
information on organizations such as Alzheimers Association, Chil-
dren of Aging Parents, or the referral service of the community-
acquired immunodeficiency syndrome task force to foster mutual
support and provide an opportunity for caregiver to discuss personal
feelings with empathetic listeners.
Help caregiver identify informal sources of support, such as family
members, friends, church groups, and community volunteers, to pro-
vide resources for obtaining an occasional or regularly scheduled
respite.
Help caregiver identify available formal support services, such as
home health agencies, municipal or county social services, hospital
social workers, physicians, clinics, and day-care centers, to enhance
coping by providing a reliable structure for support.
If caregiver seems overly anxious or distraught, gently point out
facts about care recipients mental and physical condition. Many
times, especially when care recipient is a family member, caregivers
perspective is clouded by a long history of emotional involvement.
Your input may help caregiver view the situation more objectively.
Manage: If you believe that excessive emotional involvement is hin-
dering caregivers ability to function, consider recommending Code-
pendents Anonymous, a support group for people whose preoccupa-
tion with a relationship leads to chronic suffering and diminished
effectiveness, to provide support.
Active Listening; Caregiver Support; Coping Enhancement; Counsel-
ing; Role Enhancement; Support Group
Reference
Schumacher, K., et al. (2006, August). Family caregivers: Caring for older
adults, working with their families. American Journal of Nursing, 106(8),
4049.
RISK FOR CAREGIVER ROLE STRAIN

DEFINITION
Caregiver is vulnerable for felt difficulty in performing the family
caregiver role
RISK FACTORS
Not developmentally ready for Situational factors, such as
caregiver role (e.g., young close relationship between
adult who must unexpectedly caregiver and care recipient;
care for a middle-age parent) discharge of family member
Evidence of drug or alcohol with significant home care
addiction in caregiver or care needs; inadequate environment
recipient, health impairment or facilities for providing care;
of caregiver, severity or unpre- isolation, inexperience, or
dictable course of illness, or overwork of caregiver; lack of
instability of care recipients recreation for caregiver; pres-
health ence of abuse or violence;
Evidence of codependency; simultaneous occurrence of
deviant, bizarre behavior of care other events that cause stress
recipient; dysfunctional family for family (significant personal
coping patterns that existed loss, natural disaster, economic
before the caregiving situation hardship, or major life events)
Coping Role/relationships
Knowledge
EXPECTED OUTCOMES
The caregiver will
Identify current stressors.
Identify appropriate coping strategies and will state plans to incor-
porate strategies into daily routine.
State intention to contact formal and informal sources of support.
State intention to incorporate recreational activities into daily rou-
tine.
Report satisfaction with ability to cope with stress caused by care-
giving responsibilities.
Caregiver Emotional Health; Caregiver Home Care Readiness; Care-
giver Lifestyle Disruption; CaregiverPatient Relationship; Caregiver
Physical Health; Caregiver Stressors; Caregiving Endurance Potential;
Rest
Determine: Help caregiver identify current stressors. Ask whether
stress is likely to increase or decrease in the future to evaluate the
risk of caregiver role strain.
51
Attend: Encourage caregiver to discuss coping skills used to
overcome similar stressful situations in the past to bolster caregivers
confidence in ability to manage current situation and explore ways
to apply coping strategies before caregiver becomes overwhelmed.
Help caregiver identify formal and informal sources of support,
such as home health agencies, municipal or county social services,
hospital social workers, physicians, clinics and day-care centers, fam-
ily members, friends, church groups, and community volunteers, to
plan for an occasional or regularly scheduled respite.
Encourage caregiver to discuss hobbies or diversional activities.
Incorporating enjoyable activities into the daily or weekly schedule
will discipline caregiver to take needed breaks from caregiving
responsibilities and thereby diminish stress.
Encourage caregiver to participate in a support group. Provide infor-
mation on organizations such as Alzheimers Association and Children
of Aging Parents to foster mutual support and provide an outlet for
expressing feelings before frustration becomes overwhelming.
If caregiver seems overly anxious or distraught, gently point out
facts about care recipients mental and physical condition. Many
times a caregivers perspective is clouded by a long history of emo-
tional involvement. Your input may help caregiver view the situation
more objectively. Suggest ways for caregiver to use time efficiently.
Better time management may help caregiver reduce stress.
Manage: If you believe that excessive emotional involvement is hin-
dering caregivers ability to function, consider recommending Code-
pendents Anonymous to provide support.
Caregiver Support; Home Maintenance Assistance; Referral; Respite
Care; Role Enhancement; Support Group
Reference
Perren, S., et al. (2006, September). Caregivers adaptation to change: The
impact of increasing impairment of persons suffering from dementia on
their caregivers subjective well-being. Aging and Mental Health, 10(5),
539548.
READINESS FOR ENHANCED

CHILDBEARING PROCESS
DEFINITION
A pattern of preparing for, maintaining and strengthening a healthy
pregnancy and childbirth process and care of newborn
During pregnancy
Reports appropriate prenatal lifestyle, physical preparations; man-
aging unpleasant symptoms in pregnancy
Demonstrates respect for unborn baby
Reports a realistic birth plan
Prepares necessary newborn care items
Seeks necessary knowledge (e.g., of labor & delivery, newborn
care)
Reports availability of support systems
Has regular prenatal health visits
During labor & delivery
Reports lifestyle that is appropriate for the stage of labor
Responds appropriately to the onset of labor
Is proactive in labor & delivery
Uses relaxation techniques appropriate for the stage of labor
Demonstrates attachment behavior to the newborn baby
Utilizes support systems appropriately
After birth
Demonstrates appropriate baby-feeding techniques; basic baby care
techniques
Provides safe environment for the baby
Reports appropriate lifestyle
Utilizes support system appropriately
RELATED FACTORS
Prenatal health status
Obstetrical/medical history (including perinatal risks/complications)
Cultural beliefs/expectations
Behavior
Knowledge
Roles/relationships
EXPECTED OUTCOMES
The patient/childbearing family will
Demonstrate a willingness to maintain/modify his or her lifestyle
for optimal prenatal health.
Convey confidence and knowledge of pregnancy, the labor &
delivery process, and newborn care.
53
Express appropriate self-control and readily cooperate with recom-
mendations of the healthcare team during labor & delivery.
Exhibit parentnewborn attachment after delivery.
Meet the newborns physical, social, and nutritional needs.
Prenatal Health Behavior; Knowledge: Pregnancy; Knowledge: Labor
& Delivery; Knowledge: Newborn Care; Parent Infant Attachment.
Determine: Assess baseline knowledge of prenatal self-care, labor &
delivery process, and newborn care to identify and resolve
knowledge deficits.
Perform: Provide written literature on prenatal wellness, labor &
delivery expectations, and newborn care. Providing written materials
allows adequate time to synthesize and understand new information.
Inform: Teach self-care for common prenatal discomforts to promote
patient autonomy.
Teach childbearing family labor & delivery process and newborn
care. Understanding expectations improves confidence and reduces
anxiety.
Attend: Assist childbearing family with development of a birth plan.
This allows childbearing family to participate in managing the birth
experience and promotes communication with the healthcare team.
Encourage and support childbearing family throughout the course
of the pregnancy to improve self-confidence and promote patient
compliance with health recommendations.
Manage: Refer to certified childbirth educator for classes on prenatal
care, labor & delivery (to include Cesarean birth), breast-feeding,
and newborn care. Advanced knowledge of the childbearing process
promotes empowerment and positive maternal outcomes.
Anticipatory Guidance; Childbirth Preparation; Emotional Support;
Parent Education: Infant, Prenatal Care.
Reference
Ward, S. L., & Hisley, S. M. (2009). Maternalchild nursing care: Optimizing
outcomes for mothers, children, and families. Philadelphia: F.A. Davis Com-
pany.
IMPAIRED COMFORT
DEFINITION
Perceived lack of ease, relief, and transcendence in physical, psycho-
spiritual, environmental, and social dimensions
Disturbed sleep pattern, inability to relax, and restlessness
Insufficient resources (e.g., financial, social support)
Lack of environmental or situational control
Lack of privacy
Noxious environmental stimuli
Reports being uncomfortable, hot or cold, or hungry
Reports distressing symptoms, anxiety, crying, irritability, and
moaning
Reports itching
Reports lack of contentment in situation
Treatment-related side effects (e.g., medication, radiation)
ASSESSMENT FOCUS
Cardiac Respiratory
Muscle tone Sleep patterns
Pain
EXPECTED OUTCOMES
The patient will
Maintain heart rate, rhythm, and respiration rate within expected
range during rest and activity.
Maintain muscle mass and strength.
Report pain using pain scale.
Report periods of restful sleep.
Comfort Status; Coping; Knowledge Health Promotion; Pain Control
Determine: Monitor pain level using scale 110. Using a scale will
allow evaluation of the effectiveness of pain-relieving measures.
Assess vitals signs during times of discomfort, including blood
pressure, heart rate and rhythm, and respirations. Use the patients
baseline vital signs to evaluate response to pain and response to
pain-relieving measures.
Assess sleeping patterns in response to discomfort. Interruption of
sleep is common in patients experiencing discomfort.
Perform: Provide a quiet and relaxing atmosphere. Encourage active
exercise to increase feeling of well-being. Provide pain medications
as ordered; evaluate response to evaluate effectiveness of pain-relieving
measures.
55
Inform: Teach relaxation exercises and techniques to promote
reduced pain levels, sleep, and anxiety. Teach medication administra-
tion and schedule to facilitate pain relief. Teach massage therapy to
caregiver to promote comfort.
Attend: Provide support and encouragement during periods of
discomfort. Include patient in plan of action to promote self-care.
Manage: Refer to pain management clinic if pain cannot be
controlled through relaxation and exercise. Refer to physical thera-
pist to accommodate patients level of physical activity. Refer to
massage therapist to promote relaxation. All healthcare professionals
contribute to the overall goal of maintaining comfort.
Active Listening; Aromatherapy; Calming Technique; and Coping
Enhancement
Reference
Dowd, T., Kolcaba, K., Fashinpaur, D., Steiner, R., Deck, M., & Daugherty, H.
(2007). Comparison of healing touch and coaching on stress and comfort in
young college students. Holistic Nursing Practice, 21(4), 194202.
READINESS FOR ENHANCED COMFORT

DEFINITION
A pattern of ease, relief, and transcendence in physical, psychospiritual
environmental, and/or social dimensions that can be strengthened
Expresses desire to enhance comfort
Expresses desire to enhance feelings of contentment
Expresses desire to enhance relaxation
Expresses desire to enhance resolution of complaints
Behavior
Communication
Coping
EXPECTED OUTCOMES
The patient will
Express positive perception of nursing assistance to perform activi-
ties that promote comfort.
Experience physical and psychological ease.
Develop plans to optimize level of comfort.
Report an increase in relaxation.
Coping Enhancement; Client Satisfaction; Comfort Level; Emotional
support; Environmental Management
Determine: Assess patients satisfaction with the amount of assistance
the nurse is presently offering to determine whether the patient per-
ceives self as performing physical, psychosocial, and spiritual activi-
ties as a level that is comfortable for self-changes in status.
Determine what enhancements to care can be made to provide the
patient a greater degree of comfort.
Ask for feedback from the patient at least once a day to evaluate
progress.
Perform: Adjust environmental factors, where possible, to enhance
the patients feeling of a safe and comfortable environment.
Assist patient with bathing, feeding, and toileting to ensure that
his or her needs are met.
Turn and reposition patient every 2 hr to promote comfort.
Inform: Teach patient when he or she is ready about his or her dis-
ease. Present only what patient is able and willing to absorb to pre-
vent him or her from becoming overwhelmed.
Avoid insisting that the patient accept information. Readiness is
an important factor in adult education. Provide both patient and
family with written information such as pamphlets and so forth.
57
Teach the patient and family techniques for relaxation such as
guided imagery to promote comfort and reduce anxiety.
improve ability of patient to cope with the diagnosis.
and enhance comfort.
Encourage patient to communicate with others, asking questions
and clarifying concerns based on readiness. This will enhance the
patients learning ability.
Manage: Maintain frequent communication with physicians and
other staff to determine what the patient is being told about his or
her condition.
Collaboration will foster consistency in what the patient is being
told.
Refer patient to a mental health professional/grief counselor if
denial interferes with ability of patient to function within limits.
Anxiety Reduction; Calming Techniques; Counseling; Health Educa-
tion; Reality Orientation; Truth Telling
Reference
Telford, K., et al. (2006, August). Acceptance and denial. Implications for
Nursing, 55(4), 457464.
IMPAIRED VERBAL COMMUNICATION

DEFINITION
Decreased, delayed, or absent ability to receive, process, transmit,
and use a system of symbols
Disorientation to person, space, Dyspnea
time Impaired articulation
Difficulty comprehending and Inability or lack of desire to
maintaining usual communica- speak
tion pattern Inability to speak dominant
Difficulty expressing thoughts language
verbally (aphasia, dysphasia, Inappropriate verbalizations
apraxia, dyslexia) Lack of eye contact or poor
Difficulty forming words or selective attention
sentences (aphonia, dyslalia, Stuttering or slurring
dysarthria) Visual deficit (partial or
Difficulty using or inability to total)
use facial expressions or body
language
RELATED FACTORS
Absence of significant others Differences related to develop-
Altered perceptions mental age
Alteration in self-concept, self- Environmental barriers
esteem, or central nervous Lack of information
system Physical barriers (e.g.,
Anatomical defect (e.g., cleft tracheostomy, intubation)
palate, alteration of the neuro- Physiological conditions
muscular visual system, Psychological barriers (e.g.,
phonation apparatus) psychosis, lack of stimuli)
Brain tumor Side effects of medications
Cultural differences Stress
Decrease in circulation to Weakening of the
brain musculoskeletal system
Communication Respiratory function
EXPECTED OUTCOMES
The patient/family will
Have needs met by staff members.
Express satisfaction with level of communication ability.
Maintain orientation.
Maintain effective level of communication.
Answer direct questions correctly.
59
Cognition; Communication; Communication: Expressive; Communi-
cation: Receptive; Information Processing
Determine: Observe patient closely for cues to his or her needs and
desires, such as gestures, pointing to objects, looking at items, and
pantomime to enhance understanding. Avoid continually responding
to gestures if the potential exists to improve speech to encourage
desire to improve.
Monitor and record changes in patients speech pattern or level of
orientation. Changes may indicate improvement or deterioration of
condition.
Perform: Speak slowly and distinctly in a normal tone when address-
ing patient, and stand where patient can see and hear you. These
actions promote comprehension.
Reorient the patient to reality: Call patient by name; tell him or
her your name; give him or her the background information (place,
date, and time); use television or radio to augment orientation; use
large calendars and communication boards (including alphabet and
some common words and pictures). These measures develop orienta-
tion skills through repetition and recognition of familiar objects.
Use short, simple phrases and yes-or-no questions when patient is
very frustrated to reduce frustration.
Inform: Instruct family members to use techniques listed above to
ease their frustration in communication with the patient.
Attend: Encourage attempts at communication and provide positive
reinforcement to aid comprehension.
Allow ample time for a response. Dont answer questions yourself
if patient has ability to respond. This improves patients self-concept
and reduces frustration.
Repeat or rephrase questions, if necessary, to improve communication.
Dont pretend to understand if you dont, to avoid misunderstanding.
Remove distractions from the environment during attempts at
communication. Reduced distractions improve comprehension.
Manage: Review diagnostic test results to determine improvement or
deterioration of the disease process. Adjust the care plan
accordingly.
Active Listening; Communication Enhancement: Hearing Deficit; Com-
munication Enhancement: Speech Deficit; Learning Facilitation; Touch
Reference
Philpin, S. M., et al. (2005, May). Giving people a voice: Reflections on con-
ducting interviews with participants experiencing communication
impairment. Journal of Advanced Nursing, 50(3), 299306.

COMMUNICATION
DEFINITION
A pattern of exchanging information and ideas with others that is suf-
ficient for meeting ones needs and lifes goals, and can be strengthened
Expresses willingness to enhance communication ability
Can speak or write language clearly
Forms words, phrases, and language with articulation
Uses and interprets nonverbal cues appropriately
Expresses satisfaction with ability to share information and ideas
with others
Expresses needs in an assertive way
Communication Roles and relationships
Coping Values and beliefs
EXPECTED OUTCOMES
The patient will
Maintain pulse within predetermined limit.
Maintain blood pressure within predetermined limits.
Have no arrhythmias.
Exhibit skin that is warm and dry.
Have no pedal edema.
Maintain acceptable cardiac output.
Verbalize understanding of reportable signs and symptoms.
Understand diet, medication regiment, and prescribed activity level.
Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion:
Peripheral; Vital Signs
Determine: Monitor patient at least every 4 hr for irregularities in
heart rate, rhythm, dyspnea, fatigue, crackles in lungs, jugular venous
distension, or chest pain. Any or all of these may indicate impending
cardiac failure or other complications. Report changes immediately.
Perform: Provide an environment that diminishes space between the
patient and the nurse to eliminate barriers to communication such
as noise and lack of privacy.
Incorporate questions that are open-ended and start with such
words as what, how, and could, rather than why. Open-
minded, nonthreatening questioning encourages patient to discuss
issues of concern and improve communication skills.
Schedule frequent interdisciplinary treatment team meetings
regarding communication skill development with patient. Team
meetings with the patient can ensure continuity of care.
61
Inform: Educate patient and family members about the aging
process. Educating the patient and family will help them anticipate
processes that will naturally occur again.
Teach theory of assertive behavior and role-play assertive commu-
nication approaches. Assertive training can decrease passive or
aggressive communication patterns.
Include role-playing as a teaching strategy to model methods of
enhanced verbal and nonverbal communication skills. Role-playing in
a nonthreatening safe environment can enhance communication skills.
Attend: Encourage patient verbally and nonverbally to explore
strategies to enhance self-advocacy communication skills with health
care providers. Self-advocacy communication can guide a patient
toward autonomy, confidence, and independence.
Provide support through active listening, appropriate periods of
silence, reflection on feelings, and paraphrasing and summarizing
comments. Active listening techniques encourage patient
participation in communication.
Provide patient with clear explanations for everything that will
happen to him. Ask for feedback to ensure that the patient under-
stands. Anxiety may impair patients cognitive abilities.
Manage: Identify appropriate social agencies and support groups for
the patient and provide referrals to ensure ongoing opportunities for
the patient to increase social interaction.
Active Listening; Anticipatory Guidance; Assertiveness Training;
Behavior Modification; Social Skills; Relationship-Building Enhance-
ment; Simple Guided Imagery; Support Group
Reference
Whyte, R. E., et al. (2006, September). Nurses opportunistic interventions
with patients in relation to smoking. Journal of Advanced Nursing, 55(5),
568577.
DECISIONAL CONFLICT
DEFINITION
Uncertainty about course of action to be taken when choice among
competing actions involves risk, loss, or challenge to values and beliefs
Delayed decision making
Focusing on self
Lack of experience or interference with decision making
Questioning personal values or beliefs while attempting to make a
decision
Vacillation between alternative choices
Verbal statements describing undesirable consequences of alterna-
tive actions being considered
Verbal expression of distress and uncertainty
RELATED FACTORS
Divergent sources of informa- Lack of relevant information
tion Moral obligations require
Interference with decision actions
making Moral obligations require no
Lack of experience with deci- action
sion making
Communication
Roles and relationships
Values and beliefs
EXPECTED OUTCOMES
The patient will
State feelings about the current situation.
Discuss benefits and drawbacks of treatment options.
Make minor decisions related to daily activities.
Accept assistance from family, friends, clergy, and other support
persons.
Report feeling comfortable about ability to make an appropriate,
rational choice.
Decision Making; Information Processing; Participation in
Healthcare Decisions
Determine: Assess major challenges patient will face in making deci-
sions about care, as well as factors that influence patients present
decision-making skills. This information will be useful in establishing
appropriate interventions.
63
Perform: Arrange patients environment to promote relaxation and
comfort while the patient is trying to gain control of decision making.
Assist with self-care activities while patient needs help to ensure
that ADLs are met.
Offer massage to reduce tension and assist patient to relax.
Help patient make decisions about daily activities to enhance her
feelings of control.
Help patient identify available options and possible consequences
to assist with rational, logical decision making.
Inform: Teach techniques for progressive muscle relaxation to
decrease physical and psychological signs of tension.
Attend: Encourage visits with family, friends, and clergy; provide pri-
vacy during visits to foster emotional support.
Encourage patient to express concerns about frustrations in mak-
ing decisions. Take the time to assist the patient to explore or sort
out aspects of decision making that cause him or her difficulty.
Manage: Offer written information, a reading list, or a referral to a
support group to ensure that patient will have reference material
when it is needed.
Refer to a nutritionist for information on good nutrition and fluid
management.
Active Listening; Assertiveness Training; Decision-Making Support;
Learning Facilitation; Mutual Goal-Setting
Reference
Popejoy, L. (2005). Health-related decision-making by older adults and their
families: How clinicians can help. Journal of Gerontological Nursing, 31(9),
1218.
PARENTAL ROLE CONFLICT

DEFINITION
Parent experience of role confusion and conflict in response to crisis
Disruption in care-taking routines
Expressed concern about changes in parental role and family func-
tioning, communication, and health
Expressions of inadequacy to provide for childs needs
Expressed loss of control over decisions relating to child
Expressed or demonstrated feelings of guilt, anger, fear, anxiety,
and frustration about the effect of the childs illness on family
Reluctance to participate in usual caregiving activities, even with
support
RELATED FACTORS
Change in marital status Intimidations with invasive
Home care of a child with modalities
special needs Intimidation with restrictive
Interruptions of family life due modalities
to home care regimen
Coping
EXPECTED OUTCOMES
The parents will
Communicate feelings about present situation.
Participate in their childs daily care.
Express feelings of greater control and ability to contribute more
to the childs well-being.
Express knowledge of childs developmental needs.
Hold, touch, and convey warmth and affection to child.
Use available support systems or agencies to assist with coping.
Caregiver Adaptation to Patient Institutionalization; Caregiver Care
Readiness; Coping: Family
Determine: Assess the childs special needs; age and maturity of par-
ents; roles within the family; available support systems for parents;
parentchild relationship; and presence of conflict between familys
lifestyle and childs needs. Assessment information will be useful in
establishing appropriate interventions.
65
Perform: Make changes in the environment with child-friendly
pictures, and so forth, to foster enhanced communication between
parents and child.
Provide family-centered care by involving the parents in the childs
care. Parents are responsible for decisions about the childs care.
Inform: Provide information on informed consent because parents
will be making decisions for childs care.
Teach parents about normal growth and development and advocate
that they provide as much normalcy for the child with special needs as
possible. Treating them differently will retard progress in socialization.
Teach patient and caregiver the skills necessary to manage care
adequately. Teaching will encourage compliance and adjustment to
optimum wellness.
Teach parents how to find areas in ADLs in which it is possible to
maintain control in order to avoid feelings of powerless.
Teach parents to assist child with self-care activities in a way
that maximizes the childs potential. This enables caregivers to
participate in childs care while supporting childs independence.
Attend: Encourage visit by friends to promote socialization.
Encourage parents to pay attention to needs of siblings at home,
and to discuss with siblings their feelings about having a sister or
brother with special needs. The goal is to have siblings be support-
ive but feel important in their own rites.
Provide respite care to promote emotional well-being of parents.
Encourage patents to spend time away from child to enhance their
marital relationship.
Manage: Act as a liaison between family and multidisciplinary health-
care team to provide support to the patients as they reach out for
help.
Refer parents to home care agencies and ensure that an appropri-
ate assessment is done to encourage long-term support.
Refer parents to a mental health specialist to enable support for the
family members as they continue coping with the childs special needs.
Arrange for parents to meet with parents who are coping
positively with the same kinds of issues. Peer support will help par-
ents cope with their childs issues.
Family Process Maintenance; Limit Setting; Mutual Goal-Setting;
Parenting Promotion; Role Enhancement
Reference
Secco, M. Loretta, et al. (2006). Factors affecting parenting stress among bio-
logically vulnerable toddlers. Issues in Comprehensive Pediatric Nursing,
29(3), 131156.
ACUTE CONFUSION
DEFINITION
Abrupt onset of reversible disturbances of consciousness, attention,
cognition, and perception that develop over a short period of time.
Fluctuations in LOC, psychomotor activity, cognition, and
sleepwake cycle
Hallucinations
Impaired perceptive ability
Increased agitation or restlessness
Misperceptions
Lack of motivation to initiate and follow through with goal-
directed behavior
RELATED FACTORS
Alcohol abuse Drug abuse
Delirium Fluctuations in sleepwake cycle
Dementia Over 60 years of age
Neurocognition Risk management
Nutrition Sleep/rest
EXPECTED OUTCOMES
Experience no injury.
Maintain a stable neurologic status.
Start to participate in ADLs.
Report feeling increasingly calm and improved ability to cope with
confused state.
Express an understanding of the importance of informing other
healthcare providers about episodes of acute confusion.
Cognition; Cognitive Orientation; Information Processing
Determine: Assess patients LOC and changes in behavior to provide
baseline for comparison with ongoing assessment findings. Monitor
neurologic status on a regular basis to detect any improvement or
decline in patients neurologic function.
Perform: Limit noise and environmental stimulation to prevent addi-
tional confusion.
Use appropriate safety measures to protect patient from injury.
Avoid physical restraints to prevent agitating patient.
67
Address patient by name and tell him your name to foster aware-
ness of self and environment. Also, frequently mention time, place,
and date; have a clock and a calendar in sight and refer to these aids.
Give patient short, simple explanations each time you perform a
procedure or task to decrease confusion. Speak slowly and clearly
and allow time to respond to reduce frustration.
Schedule nursing care to include quiet times to help avoid sensory
overload. Plan patients routine and be consistent to foster task com-
pletion and reduce confusion.
Ask family members to bring labeled family photos and articles to
create a more secure environment for patient. Keep patients posses-
sions in the same place. A consistent, stable environment reduces
confusion and frustration and aids completion of ADLs.
Inform: Review home measures to use and report if patient begins to
exhibit signs of confusion. Tell caregiver to provide short explanations
of activities and orient the patient frequently; speak slowly and clearly
and allow patient time to respond; and provide patient with a consis-
tent routine. Teaching empowers patient and family members to take
greater responsibility for the healthcare needs.
Attend: Have a staff member stay at patients bedside, if necessary,
to protect him or her from harm.
Enlist the aid of family member to help calm patient. Patiently
encourage patient to perform ADLs, dividing tasks into small, criti-
cal units.
Be patient and specific in providing instructions. Allow time for
patient to perform each task. These measures enhance his or her self-
esteem as well as help prevent complications related to inactivity.
Encourage family members to share stories and discuss familiar
people and events with patient to promote a sense of continuity and
create a sense of security and comfort. Support family members
attempts to interact with patient to provide positive reinforcement.
Allow time before and after visits for family members to express feel-
ings. Listening to family members in an open and nonjudgmental
manner promotes coping and may help you assess and monitor
patients condition. Reassure patient and family that confusion is tem-
porary to help relieve anxiety. Always include patient in discussions.
Manage: Confer with physician about diagnostic test results, patients
progress in behavior, and patients LOC. A collaborative approach to
treatment helps ensure high-quality care and continuity of care.
Cognitive Stimulation; Delirium Management; Hallucination
Management; Orientation
Reference
Buettner, L., & Fitzsimmons, S. (2006, July). Mixed behaviors in dementia: The
need for a paradigm shift. Journal of Gerontological Nursing, 32(7), 1522.
CHRONIC CONFUSION
DEFINITION
Irreversible, long-standing, and/or progressive deterioration of intel-
lect and personality characterized by decreased ability to interpret
environmental stimuli; decreased capacity for intellectual thought
processes; and manifested by disturbances of memory, orientation,
and behavior
Altered interpretation, response to stimuli, and/or personality
No change in LOC
Clinical evidence of organic impairment
Short- and long-term memory loss
Progressive or long-standing impaired cognition or socialization
RELATED FACTORS
Alzheimers disease Korsakoffs psychosis
Cerebral vascular accident Multi-infarct dementia
Head injury
Neurocognition
Role/relationships
Self-care
EXPECTED OUTCOMES
The patient will
Remain free of injury caused by confusion.
Exhibit no signs of depression.
Maintain weight.
Have an environment structured for maximum functioning.
Participate in selected activities to fullest extent possible.
Receive adequate emotional support.
Family members will
Discuss strategies to provide care and help patient cope.
Maintain safety of patients home environment.
Receive information on the options available for long-term care.
Assist patient to prepare for relocation to long-term care facility.
Client Satisfaction: Safety; Cognition; Cognitive Orientation
Determine: Assess patients cognitive abilities and changes in behav-
ior to provide baseline data.
Weigh patient and include instructions for regular weighing as
part of care plan to monitor patients nutritional status.
Perform: Take steps to provide a stable physical environment and
consistent daily routine for patient. Stability and consistency enhance
functioning.
69
Inform: Teach family members or caregiver strategies to help patient
cope with his condition: Place an identification bracelet on patient to
promote safety; touch patient to convey acceptance; avoid unfamiliar
situations when possible to help ensure consistent environment; provide
structured rest periods to prevent fatigue and reduce stress; refrain from
asking questions patient cant answer to avoid frustration; provide
finger foods if patient wont sit and eat to ensure adequate nutrition;
select activities based on patients interests and abilities and praise him
or her for participating in activities to enhance his or her sense of self-
worth; use television and radio carefully to avoid sensory overload;
limit choices patient has to make to provide structure and avoid confu-
sion; label familiar photos to provide a sense of security; use symbols,
rather than written signs, to identify patients room, bathroom, and
other facilities to help patient identify surroundings; place patients
name in large block letters on clothing and other belongings to help
him recognize his belongings and prevent them from becoming lost.
Attend: Encourage family members to watch mental status
assessments to provide a more accurate view of patients abilities.
Evaluate patients ability to perform self-care activities, including
ability to function alone and drive a car. Safety is a primary concern.
Ask family members about their ability to provide care for patient
to assess the need for assistance.
Project an attentive, nonjudgmental attitude when listening to
them to help ensure that you receive accurate information.
Manage: Assist family members in contacting appropriate community
services. If necessary, act as an advocate for patients within health-
care system to help secure services needed for ongoing care.
Provide family members with information concerning long-term
healthcare facilities. If patient is to be moved to a long-term care
facility, explain the decision to him in as simple and gentle terms as
possible to facilitate comprehension.
Allow patient to express feelings regarding the move to facilitate
grieving over loss of independence. Provide psychological support to
patient and family members to alleviate stress they may experience
during relocation.
Communicate all aspects of discharge plan to staff members at
patients new residence. Documenting a discharge plan and commu-
nicating it to caregivers help ensure continuity of care. Interventions
should ensure patients dignity and rights.
Cognitive Stimulation; Dementia Management; Family Involvement
Promotion; Reality Orientation
Reference
Rader, J., et al. (2006, April). The bathing of older adults with dementia.
American Journal of Nursing, 106(4), 4048.
RISK FOR ACUTE CONFUSION

DEFINITION
At risk for reversible disturbances of consciousness, attention, cogni-
tion, and perception that develop over time
RISK FACTORS
Alcohol use Male gender
Decreased mobility or restraints Medication/drugs
Dementia 60 years
Fluctuation in sleepwake Pain
cycle Metabolic abnormalities
History of stroke Sensory deprivation
Impaired cognition Substance abuse
Infection Urine retention
EXPECTED OUTCOMES
The patient will
Remain free from injury.
Have a stable neurologic status.
Obtain adequate amounts of sleep.
Maintain optimal hydration and nutrition.
Begin to participate in ADLs.
Report feeling increasingly calm.
Family members will
Report an improved ability to cope with the patients confused state.
State the causes of acute confusion.
Express the necessity for informing healthcare providers about
acute confusion.
Cognitive Orientation; Information Processing; Memory
INTERVENTION AND RATIONALES
Determine: Assess patients LOC and changes in behavior to provide
baseline for comparison with ongoing assessment findings.
Monitor neurologic status on a regular basis to detect
improvement or decline in the patients neurologic function.
Perform: Use appropriate safety measures to protect patient from
injury. Avoid physical restraints to prevent agitating patient.
Address patient by name and tell him or her your name, mention
time, place, and date frequently throughout day, and have a large
clock and a calendar close by and refer to those aids to foster
awareness of self and environment.
71
Give patient short, simple explanations each time you perform a
procedure or task to decrease confusion. Speak slowly and clearly
and allow patient ample time to respond to reduce his or her frus-
tration and promote task completion.
Schedule nursing care to provide quiet times for patient to help
avoid sensory overload. Follow consistent patient routine to aid task
completion and reduces confusion.
Keep patients possessions in the same place. A consistent, stable
environment reduces confusion and frustration and aids completion
of ADLs. Ask family to bring labeled family photos and other
favorite articles to create a more secure environment for patient.
Encourage patient to perform ADLs, dividing tasks into small,
critical units. Be patient and specific in providing instructions. Allow
time for patient to perform each task. These measures enhance his
or her self-esteem as well as help prevent complications related to
inactivity.
Inform: Discuss episodes of acute confusion with patient and family
members to make sure they understand the cause of confusion.
Review measures family members can take at home to help
patient if he or she begins to exhibit signs of confusion and to
report future episodes. Tell them to give patient short explanations
of activities; remind him of time, place, and date frequently; speak
slowly and clearly and allow patient ample time to respond; and
provide patient with a consistent routine. Teaching empowers
patient and family to take greater responsibility for his or her
healthcare needs.
Attend: Have a staff member stay at patients bedside, if necessary, to
protect patient from harm. Enlist family member to help calm patient.
Encourage family to share stories and discuss familiar people and
events with patient to promote a sense of continuity, security, and
comfort.
Manage: Confer with physician about diagnostic test results,
patients progress in behavior, and patients LOC. A collaborative
approach to treatment helps ensure high-quality care and continuity
of care.
Behavior Management: Overactivity/Inattention; Cognitive Stimula-
tion; Delirium Management; Hallucination Management; Reality
Orientation
Reference
Cacchione, P. Z., et al. (2003, November). Risk for acute confusion in
sensory-impaired, rural, long-term care elders. Clinical Nursing Research,
12(4), 340355.
CONSTIPATION
DEFINITION
Decrease in normal frequency of defecation accompanied by difficult
or incomplete passage of stool and/or passage of excessively hard,
dry stool
Palpable rectal or abdominal mass
Borborygmi, hypoactive or hyperactive bowel sounds, or abdomi-
nal dullness on percussion
Bright red blood with stools; bark-colored or black, tarry stools;
hard, dry stools; or oozing liquid stools
Change in bowel pattern; decreased frequency and volume of stool
Changes in mental status, urinary incontinence, unexplained falls,
or elevated body temperature in older adults
Distended or tender abdomen and feeling of fullness or pressure
General fatigue, anorexia, headache, indigestion, nausea, or vomiting
Severe flatus; straining and possible pain during defecation
RELATED FACTORS
Functional: habitual denial or Mechanical: electrolyte imbal-
ignoring urge to defecate, ance, hemorrhoids, prostate
irregular defecation patterns, enlargement, rectal abscess,
insufficient physical activity anal fissure, or stricture
Psychological: depression, Physiological: change in eating
emotional stress, mental patterns or usual foods, dehy-
confusion dration, inadequate dentition
Pharmacological: aluminum- or oral hygiene, insufficient
containing antacids, and drugs fiber or fluid intake
that affect bowels
Elimination Pharmacological function
Nutrition Tissue integrity
EXPECTED OUTCOMES
The patient will
Participate in development of bowel program.
Report urge to defecate, as appropriate.
Increase fluid and fiber intake.
Report easy and complete evacuation of stools.
Have elimination pattern within normal limits.
Adopt personal habits that maintain normal elimination.
Bowel Elimination; Hydration; Nutritional Status: Food & Fluid
Intake
73
Determine: Monitor frequency and characteristics of patients stool
daily. Careful monitoring forms the basis of an effective treatment plan.
Monitor and record patients fluid intake and output. Inadequate
fluid intake contributes to dry feces and constipation.
Perform: Provide privacy for elimination to promote physiological
functioning.
Plan and implement an individualized bowel regimen to establish
a regular elimination schedule; and exercise routine to promote
abdominal and pelvic muscle tone.
Inform: Emphasize importance of responding to urge to defecate. A
timely response to the urge to defecate is necessary to maintain nor-
mal physiological functioning.
Teach patient to locate public restrooms and to wear easily remov-
able clothing on outings to promote normal bowel functioning.
Teach patient to massage abdomen once per day and how to locate
and gently massage along the transverse and descending colon. In the
older patient, the neural centers in the lower intestinal wall may be
impaired, making it more difficult for the body to evacuate feces.
Massage may help stimulate peristalsis and the urge to defecate.
Teach patient sensible use of laxatives and enemas to avoid laxa-
tive dependency. Overuse of laxatives and enemas may cause fluid
and electrolyte loss and damage to intestinal mucosa.
Attend: Encourage patient to use a bedside commode or walk to toi-
let facilities to encourage normal position for evacuation. Encourage
intake of high-fiber foods to supply bulk for normal elimination and
improve muscle tone. Unless contraindicated, encourage fluid intake
of 68 glasses (1,4201,900 ml) daily to maintain normal metabolic
processes.
Manage: Help patient understand diet modification plan along with
dietitian, if appropriate, to encourage compliance with prescribed
diet.
Bowel Management; Constipation/Impaction Management; Exercise
Promotion; Fluid Management; Nutrition Management
Reference
Wilson, L. A. (2005, November). Understanding bowel problems in older peo-
ple: Part 1. Nursing Older People, 17(8), 2529.
PERCEIVED CONSTIPATION
DEFINITION
Self-diagnosis of constipation and abuse of laxatives, enemas, and
suppositories to ensure a daily bowel movement
Expectation of passage of stools at the same time each day
Overuse of laxatives, enemas, and/or suppositories
RELATED FACTORS
Cultural health beliefs Faulty appraisal
Family health beliefs Impaired thought processes
Activity/exercise Elimination
Coping Fluid and electrolytes
Behavior Nutrition
Emotional
EXPECTED OUTCOMES
The patient will
Decrease use of laxatives, enemas, or suppositories.
State understanding of normal bowel function.
Discuss feelings about elimination pattern.
Have a return-to-normal elimination pattern.
Experience bowel movement every _____ day(s) without laxatives,
enemas, or suppositories.
State understanding of factors causing constipation.
Get regular exercise.
Describe changes in personal habits to maintain normal
elimination pattern.
State intent to use appropriate resources to help resolve emotional
or psychological problems.
Adherence Behavior; Bowel Elimination; Health Beliefs; Health
Beliefs: Perceived Threat; Knowledge: Health Behavior
Determine: Assess patients dietary habits and encourage modification
to include adequate fluids, fresh fruits and vegetables, and whole grain
cereals and breads, which supply necessary bulk for normal elimination.
Perform: If not contraindicated, increase patients fluid intake to about
3 qt (3 L) daily to increase functional capacity of bowel elimination.
Establish and implement an individualized bowel elimination regi-
men based on the patients needs. Knowledge of normal body func-
tions will improve patients understanding of problem.
Inform: Explain normal bowel elimination habits so patient can bet-
ter understand normal and abnormal body functions.
75
Instruct patient to avoid straining during elimination to avoid tis-
sue damage, bleeding, and pain.
Instruct patient that abdominal massage may help relieve discom-
fort and promote defecation because it triggers bowels spastic
reflex.
Inform patient not to expect a bowel movement every day or even
every other day to avoid the use of poor health practices to stimu-
late elimination.
Attend: Encourage patient to engage in daily exercise, such as brisk
walking, to strengthen muscle tone and stimulate circulation.
Encourage patient to evacuate at regular times to aid adaptation
and routine physiological function.
Urge patient to avoid taking laxatives, if possible, or to gradually
decrease their use to avoid further trauma to intestinal mucosa.
Reassure patient that normal bowel function is possible without lax-
atives, enemas, or suppositories to give patient the necessary confi-
dence for compliance.
Manage: Give information about self-help groups, as appropriate, to
provide additional resources for patient and family.
Anxiety Reduction; Bowel Management; Counseling; Health Educa-
tion; Nutrition Management; Teaching: Individual
Reference
Hernando-Harder, A. C., et al. (2007, March). Intestinal gas retention in
patients with idiopathic slow-transit constipation. Digestive Diseases and
Sciences. [Epub ahead of print.]
RISK FOR CONSTIPATION

DEFINITION
At risk for a decrease in normal frequency of defecation accompa-
nied by difficult or incomplete passage of stool and/or passage of
excessively hard, dry stool
RISK FACTORS
Functional: Habitual denial anti-inflammatory agents,
and ignoring urge to defecate, sedatives, aluminum-containing
recent environmental changes, antacids, laxative overuse, iron
inadequate toileting, irregular salts, anticholinergics, antide-
defecation habits, insufficient pressants, anticonvulsants,
physical activity, and abdomi- antilipemic agents, calcium
nal muscle weakness channel blockers, calcium
Mechanical: Rectal abscess or carbonate, diuretics, sympath-
ulcer, pregnancy, rectal anal omimetics, opiates, and
stricture, postsurgical obstruc- bismuth salts
tion, rectal anal fissures, mega- Physiological: Insufficient fiber
colon (Hirschsprungs disease), intake, dehydration, inadequate
electrolyte imbalance, tumors, dentition/oral hygiene, poor
prostate enlargement, eating habits, insufficient fluid
rectocele, rectal prolapse, neu- intake, change in usual
rologic impairment, foods/eating patterns, and
hemorrhoids, and obesity decreased motility of GI tract
Pharmacological: Psychological: Emotional stress,
Phenothiazines, nonsteroidal mental confusion, depression
Activity/rest Fluid and electrolytes
Behavior Nutrition
EXPECTED OUTCOMES
The patient will
Experience no signs or symptoms of constipation.
Maintain bowel movement every ______ day(s).
Consume a high-fiber or high-bulk diet, unless contraindicated.
Maintain fluid intake of ______ ml daily (specify).
Express understanding of the relationship between constipation
and dietary intake, bulk, and activity.
Express understanding of preventive measures, such as eating fruit
and whole grain breads and cereals and engaging in mild activity,
if appropriate.
Bowel Elimination; Self-Care: Toileting
77
Determine: Assess bowel sounds and check patient for abdominal
distention. Monitor and record frequency and characteristics of
stools to develop an effective treatment plan for preventing constipa-
tion and fecal impaction.
Record intake and output accurately to ensure accurate fluid
replacement therapy.
Perform: Initiate bowel program. Place patient on a bedpan or com-
mode at specific times daily, as close to usual evacuation time (if
known) as possible, to aid adaptation to routine physiological func-
tion.
Administer a laxative, an enema, or suppositories, as prescribed,
to promote elimination of solids and gases from GI tract. Monitor
effectiveness.
Inform: Teach patient to gently massage along the transverse and
descending colon to stimulate the bowels spastic reflex and aid in
stools passage.
Instruct patient, family member, or caregiver in the relationship
between diet, activity and exercise, and fluid intake and constipation
to discourage departure from prescribed diet and assist in promoting
elimination.
Review care plan with patient, family member, or caregiver,
emphasizing the relationship between the risk factors for
constipation and preventive measures to foster understanding.
Attend: Encourage fluid intake of 212 qt (2.5 L) daily, unless
contraindicated, to promote fluid replacement therapy and hydration.
Manage: Consult with a dietitian about how to increase fiber and
bulk in patients diet to the maximum amount prescribed by the
physician to improve intestinal muscle tone and promote
comfortable elimination.
Include a program of mild exercise in your care plan to promote
muscle tone and circulation.
Bowel Management; Constipation/Impaction Management; Exercise
Promotion; Fluid Management; Fluid Monitoring; Nutrition
Management
Reference
Norton, C. (2006, FebruaryMarch). Constipation in older patients: Effects on
quality of life. British Journal of Nursing, 15(4), 188192.
CONTAMINATION
DEFINITION
Exposure to environmental contaminants in doses sufficient to cause
adverse health effects
(These are dependent on the causative agent. Agents cause a variety
of individual organ responses as well as systemic responses.)
Pesticides: Have dermatological, GI, neurological, pulmonary, and
renal effects. Categories include insecticides, herbicides, fungicides,
antimicrobials, and rodenticides.
Chemicals: Have dermatological, immunological, neurological, pul-
monary, and renal effects. Categories include petroleum-based agents,
anticholinesterases, Type I agents act on proximal tracheobronchial
tract, Type II agents act on aveoli and produce systemic effects.
Biologicals: Have dermatological, GI, neurological, pulmonary, and
renal effects.
Radiation: Have dermatological, GI, neurological, pulmonary, and
renal effects. Categories include internal such as exposure through
ingestion of radioactive material or external such as direct contact
with radiological material.
Pollution: Have dermatological and pulmonary effects. Categories
include trash, raw sewage, industrial waste.
RELATED FACTORS
External: Chemical contamination of food or water, exposure to
bioterrorism, radiation, and exposure to areas of contamination.
Internal: Extremes of age, nutritional factors, preexisting disease
states, pregnancy, previous exposure.
Populations
Risk management
EXPECTED OUTCOMES
The patient/community will
Have minimized health effects associated with contamination.
Utilize health surveillance data system to monitor for contamina-
tion incidents.
Utilize disaster plan to evacuate and triage affected members.
Minimize exposure to contaminants.
Anxiety Level; Community Health Status; Fear Level
Determine: Triage, stabilize, transport, and treat affected community
members. Accurate triage and early treatment provide the best
chance of survival to affected persons.
79
Monitor individuals for therapeutic effects, side effects, and com-
pliance with postexposure drug therapy. Drug therapy may extend
over a long period of time and will require monitoring for compli-
ance as well as therapeutic and side effects.
Perform: Help individuals cope with contamination incident; use
groups that have survived terrorist attacks as useful resource for vic-
tims to aid in support; those with experience can share reactions
and useful coping mechanisms.
Help individuals deal with feelings of fear, vulnerability, and grief
to minimize risk of traumatic stress.
Decontaminate persons, clothing, and equipment using approved
procedure. Victims may first require decontamination before entering
health facility to receive care in order to prevent the spread of con-
tamination.
Use appropriate isolation precautions, including universal,
airborne, droplet, and contact isolation. Proper use of isolation pre-
cautions prevents cross-contamination.
Inform: Provide accurate information on risks involved, preventive
measures, and use of antibiotics and vaccines to enhance the use of
protective measures.
Attend: Encourage individuals to talk to others about their fears.
Interventions aimed at supporting an individuals coping can help
the person deal with feelings of fear, helplessness, and loss of
control that are normal reactions in a crisis situation.
Manage: Collaborate with other agencies (local health department,
emergency medical services, state and federal agencies). Communica-
tion and collaboration among agencies increase ability to handle
crises efficiently and correctly.
Anxiety Reduction; Crisis Intervention; Environmental Management;
Infection Control; Health Education; Triage
Reference
Chung, S., & Shannon, M. (2005). Hospital planning for acts of terrorism
and other public health emergencies involving children. Archives of Disease
in Childhood, 90(12), 13001307.
RISK FOR CONTAMINATION

DEFINITION
Accentuated risk of exposure to environmental contaminants in
doses sufficient to cause adverse health effects
RISK FACTORS
External (temperature, wind, geographic
Environmental contaminants area)
in the home Playing in outdoor areas
Exposure to heavy metals or where environmental contami-
chemicals, bioterrorism, nants are present
atmospheric pollutants, disas- Social factors, such as
ter, radiation overcrowding, sanitation,
Insufficient or absent use of poverty, personal and house-
decontamination protocol hold hygiene practices, lack
Flooding, earthquakes, atmos- of access to healthcare
pheric pollutants, or other Internal
natural disasters Age (less than 5 years or older
Contamination of aquifers by adult)
septic tanks Female gender
Industrial plant emissions, Concomitant or previous
discharge of contaminants by exposures
industries Developmental characteristics
Intentional or accidental con- (gestational age during exposure)
tamination of food and water Nutritional factors or dietary
supply practices
No or inappropriate use of Preexisting disease states: gen-
protective clothing der, occupation, history of
Physical factors, such smoking; presence of bacteria,
as climactic conditions viruses, toxins, vectors
Populations
Risk management
EXPECTED OUTCOMES
The patient/community will
Remain free from adverse effects of contamination.
Utilize health surveillance data system to monitor for contamina-
tion incidents.
Participate in mass casualty and disaster readiness drills.
Remain free from contamination-related health effects.
Have minimal exposure to contaminants.
Community Disaster Readiness; Community Health Status; Health
Beliefs: Perceived Threat; Knowledge: Health Behavior; Knowledge:
Health Resources; Risk Control
81
Determine: Monitor individuals for therapeutic effects, side effects,
and compliance with postexposure drug therapy. Drug therapy may
extend over a long period of time and will require monitoring for
compliance as well as therapeutic and side effects.
Perform: Conduct surveillance for environmental contamination;
notify agencies authorized to protect the environment of
contaminants in the area. Early surveillance and detection are criti-
cal components of preparation.
Assist individuals in relocating to safer environment to decrease
their risk of contamination.
Modify environment to minimize risk. Modification of the
environment will decrease the risk of actual contamination.
Implement decontamination of persons, clothing, and equipment
by using approved procedure. Victims may first require decontami-
nation before entering health facility to receive care in order to pre-
vent the spread of contamination.
Use appropriate isolation precautions: universal, airborne, droplet,
and contact isolation. Proper use of isolation precautions prevents
cross-contamination by contaminating agent.
Inform: Provide accurate information on risks involved, preventive
measures, use of antibiotics and vaccines to reduce anxiety and
increase compliance.
Attend: Assist community members with feelings of fear and vulner-
ability. Interventions aimed at supporting an individuals coping help
the person deal with feelings of fear, helplessness, and loss of
control that are normal reactions in a crisis situation.
Manage: In conjunction with other healthcare providers, schedule
mass casualty and disaster readiness drills. Practice in handling con-
tamination occurrences will decrease the risk of exposure during
actual contamination events.
Bioterrorism Preparedness; Communicable Disease Management;
Community; Community Disaster Preparedness; Environmental Man-
agement: Safety; Environmental Risk Protection; Health Education;
Health Policy Monitoring; Health Screening; Immunization/
Vaccination Management; Risk Identification; Surveillance: Safety
Reference
Chung, S., & Shannon, M. (2005). Hospital planning for acts of terrorism
and other public health emergencies involving children. Archives of Disease
in Childhood, 90(12), 13001330.
COMPROMISED FAMILY COPING

DEFINITION
Usually supportive primary person (family member or close friend)
provides insufficient, ineffective, or compromised support, comfort,
assistance, or encouragement that may be needed by the patient to
manage or master adaptive tasks related to health challenge
Attempts to assist the patient with unsatisfactory results
Displays of protective behavior disproportionate to the patients
abilities or need for autonomy (family member)
Expresses concern about the familys response to health problem
Reports preoccupation with personal reaction to the patients
health
RELATED FACTORS
Exhaustion of supportive Lack of reciprocal support
capacity of significant people Temporary preoccupation by a
Incorrect information by a pri- significant person
mary person
Behavior Coping
Communication Emotional status
EXPECTED OUTCOMES
The family members will
Assume responsibility for roles and activities formerly held by the
patient.
Express feelings about assuming responsibility of care for an older
family member.
The patient and family members will
Identify and make use of appropriate community services.
Express satisfaction with improved ability to cope with current crisis.
Caregiver Emotional Health; CaregiverPatient Relationship; Care-
giver Stressors; Family Coping; Family Normalization
Determine: Identify the primary caregiver in family and assess roles
of other family members. Determine usual coping mechanisms
employed by this patient and family. Describe patterns of communi-
cation used in problem solving. Identify what support systems exist
for the family and patient outside the family. Identify strengths and
weakness in the familys communication patterns. Assessment data
will assist with establishment of interventions.
Perform: Direct development of short- and long-term goals by the
patient and family members. Initially, the family members will need
83
help from the caregiver until they understand more about the
process of planning.
Identify appropriate community services for the family to assist
with coping.
Inform: Educate patient and family members about the process of
aging to assist patient and family to understand how changes in the
patient have affected the family.
Teach family members ways of maximizing the use of coping
strategies that seem to have worked for them in the past. Teach new
coping strategies and have family members role model them. Prac-
tice will help the family practice the behaviors in real situations.
Attend: Avoid becoming involved in a power struggle between
patient and family members. The patient may no longer be able to
fill ordinary roles and the sudden shift in roles may lead to a power
struggle.
Encourage family members to express feelings about caring for an
older family member. Be nonjudgmental when listening to the
family; discuss the issues associated with caring for an older person.
If the nurse is judgmental, the family members may not be comfort-
able discussing their problem.
Provide emotional support for primary caregiver. Some families
may hesitate to accept outside help. Other families may be unwilling
to make even small sacrifices to care for an older family member. If
family members have not been supportive or caring for the elder
member before, they are unlikely to change.
Manage: Refer to community agencies (e.g., adult day care, respite
care, and geriatric outreach services) that can assist the family in
caring for the elder. Communicate to the hospice nurse where the
patient is at present in coping with the terminal illness.
Refer to case manager or social service to assist with ongoing
coordination of the patients needs after hospitalization.
Refer to a member of the clergy or a spiritual counselor when
deemed appropriate. Patients will often be more inclined to talk to a
spiritual counselor.
Caregiver Support; Coping Enhancement; Family Involvement
Promotion; Respite Care
Reference
Garity, J. (2006). Caring for a family member with Alzheimers disease: Cop-
ing with caregiver burden post-nursing home placement. Journal of Geron-
tological Nursing, 32(6), 3948.
DEFENSIVE COPING
DEFINITION
Repeated projection of falsely positive self-evaluation based on a
self-protective pattern that defends against underlying perceived
threats to positive self-regard
Denial of obvious problems Projection of blame
Denial of obvious weaknesses Projection of responsibility
Difficulty establishing Rationalization of failures
relationships Ridicule of others
Difficulty in perception of Superior attitude toward
reality testing others
RELATED FACTORS
Conflict between self-perception Low level of confidence in
and value system others
Fear of failure Low level of self-confidence
Fear of humiliation Uncertainty
Fear of repercussion Unrealistic expectation of
Lack of resilience self
Behavior Knowledge
Emotional Roles/relationships
Coping
EXPECTED OUTCOMES
The patient will
State the reason for hospitalization.
Verbally describe self-perception, body image, success, and failures.
Engage in decision making about care.
Express a responsible attitude toward own behavior.
Demonstrate follow-through in decisions related to healthcare.
Interact with others in a socially acceptable manner.
Acceptance: Health Status; Coping; Self-Esteem; Social Interaction
Skills
Determine: Assess patients understanding of current illness; relation-
ships with family and friends; self-esteem; self-perception; support
systems; spiritual support. Specific assessment information will assist
in developing an accurate plan of care for the individual.
Perform: Assist patient to compile a list of this that he likes and dis-
likes about his present situation. Performing this exercise can help
85
the patient identify aspects of self and identify changes he would
like to make with specific variables.
Have patient perform as many self-care activities as possible, and
make treatment-related decisions to encourage a sense of autonomy
and promote compliance.
Provide a structured daily routine. Structure may help provide an
alternative to self-absorption.
Inform: Teach patient relaxation techniques such as guided
imagery, deep breathing, meditation, aromatherapy, and progres-
sive muscle relaxation. Purposeful relaxation efforts helps reduce
anxiety.
Teach patient strategies for positive thinking. Work specifically
to identify negative thoughts and rephrase them in a positive way.
Making the patient conscious of negative thoughts will help
reinforce the need to think about things and people in a more
positive way.
Attend: Arrange for interaction between the patient and family
or friends and observe the interaction patterns. This allows
the nurse to provide feedback about the effectiveness of communi-
cation.
Allow time for patient to talk about his or her frustration. Speak-
ing to a sensitive listener may help to reduce some frustration and
may lead to new ideas about how to help the patient resolve his or
her issues.
Provide positive feedback to patient when he or she assumes
responsibility for his or her own behavior in order to reinforce posi-
tive coping behaviors.
Manage: Encourage the patient to meet with someone who is coping
successfully with a similar problem. This may assist the patient to
work toward a positive outcome.
Encourage the patient to consider participating in a support
group. Participation in such a group may help the patient cope
more effectively, as well as establish new relationships.
Refer to case manager/social worker to ensure that follow-up is
provided.
Calming Techniques; Coping Enhancement; Emotional Support; Self-
Awareness Enhancement; Self-Responsibility Enhancement
Reference
Schwinghammer, S. A., et al. (2006). Different selves have different effects:
Self-activation and defensive social comparison. Personality and Social
Psychology Bulletin, 32(1), 2739.
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DISABLED FAMILY COPING

DEFINITION
Behavior of significant person (family members or other primary per-
son) that disables his or her capabilities and the patients capabilities
to effectively address tasks essential to either persons adaptation to
the health challenge
Intolerance Distortion of reality regarding
Agitation, depression, aggres- patient
sion, hostility Impaired restructuring of a
Taking on illness of patient meaningful life
Rejection
RELATED FACTORS
Arbitrary handling of familys Significant person with chroni-
resistance to treatment cally unexpressed feelings (e.g.,
Dissonant coping styles among guilt, anxiety, hostility,
significant people despair)
Basic breast-feeding knowledge
Communication Knowledge
EXPECTED OUTCOMES
To the extent possible, family members will participate in aspects of
patients care without evidence of increased conflict.
The patient will
Express confidence in his or ability to make decisions despite pres-
sure from family members.
Contact appropriate sources of support outside the family.
Take steps to ensure that care needs are met despite familys short-
comings.
Express greater understanding of emotional limitations of family
members.
Caregiver Emotional Health; CaregiverPatient Relationship; Care-
giving Endurance Potential; Family Coping
Determine: Assess effects of patients disease on ability of family to
cope to identify strengths and weaknesses in patients patterns of
coping.
Describe role relationships in the family. Evaluate changes that
occur in family relationships during the course of the patients hos-
pitalization. This information will be helpful in making a plan.
87
Have patient identify support systems outside the family to encour-
age responsibility for knowing what support systems are helpful.
Perform: Engage family in assisting with physical aspects of patient
care. Family members should have an opportunity to overcome dys-
functional behavior.
Develop short- and long-term goals with both patient and family.
Problems associated with coping may will require long-term plan-
ning to resolve.
Inform: Teach patient strategies to discuss, to confront in a positive
way that will help cope with the present situation. Role-play coping
strategies with the patient to reinforce new adaptive behaviors.
Educate family members about resources in the community that
can assist them with the patient after hospitalization.
Teach patient decision-making skills and assist him or her to prac-
tice with simple decisions. Beginning with simple decisions will
begin helping the patient lay out options before deciding.
Attend: Maintain objectivity when dealing with family conflicts. Do
not become embroiled in the dynamics of a dysfunctional family in
order to maintain objectivity and effectiveness.
Focus on being a patient advocate. Reaffirm patients right to
make decisions without interference from family members. Encour-
age patient to seek help family cannot provide by participating in
support group.
Help patient select a support group that best meets personal
needs. Participation in a support group may improve the patients
ability to cope as well as provide meaningful relationships.
Listen attentively to patients expression of pain over unresolved
conflicts with family members. The patient may have to grieve over
the fact that he or she does not have an ideal family, capable of
meeting his emotional needs. Therapeutic listening helps patient to
understand himself and his family better and to understand how
conflicts from the past affect his behavior.
Manage: Refer patient to a home health agency, homemaker service,
meals-on-wheels, or other appropriate community services for assis-
tance and follow-up. Use of various community services may help
make up the familys shortcomings in coping.
Anger Control Assistance; Caregiver Support; Family Involvement
Promotion; Family Mobilization; Family Support
Reference
Andershed, B. (2006, September). Relatives in end-of-life care, Part 1: A sys-
tematic review of the literature the last five years, January, 1999February,
2004. Journal of Clinical Nursing, 15(9), 11581169.
INEFFECTIVE COPING
DEFINITION
Inability to form a valid appraisal of the stressors, inadequate
choices of practiced responses, and/or inability to use available
resources
Change in communication patterns
Decreased use of social support
Destructive behavior toward self or others
Difficulty asking for help
Fatigue
High illness rate
Inability to meet basic needs and role expectations
Statements indicating inability to cope
RELATED FACTORS
High degree of threat
Inability to conserve adaptive energies
Inadequate resources available
Behavior
Communication
Coping
EXPECTED OUTCOMES
The patient will
Verbalize increased ability to cope.
Expand support network to meet social and emotional needs.
Locate and use appropriate resources for help in problem solving.
Report increased ability to meet demands of daily living.
Make changes to environment to ensure enhanced coping or move
into long-term care facility, as needed.
Coping; Decision Making; Impulse Self-Control; Information
Processing; Social Interaction Skills
Determine: Monitor physiological responses to increased activity
level, including respirations, heart rate and rhythm, and blood pres-
sure. Vital signs are likely to change as the patient deals with the
frustration from poor coping strategies. Assess understanding of the
current health problem and desire to participate in treatment.
Perform: Listen to the patient. Respond in a matter-of-fact, nonjudg-
mental manner. Judgmental responses will impede the development
of a trusting relationship. Practice guided imagery and deep breath-
ing with the patient to help the patient relax.
89
Inform: Provide patient with information about relaxation
techniques. These techniques take practice. Information will help the
patient understand the benefit.
Teach patient about her disease process and explain treatments to
allay fear and allow the patient to regain sense of control.
Teach positive coping strategies and have patient role-play them
and give praise for successful modeling. This will help to reinforce
coping behaviors.
Attend: Assist patient to develop short- and long-term goals to
encourage better coping and a roadmap to measure progress.
Provide emotional support and encouragement to help improve
patients negative self-concept and motivate the patient to perform
ADLs. Involve patient in planning and decision making. Having the
ability to participate will encourage greater compliance with
treatment plan. Encourage patient to engage in social activities with
people of all age groups. Participation once a week will help relieve
the patients sense of isolation.
Manage: Refer patient for professional psychological counseling. For-
mal counseling helps ease the nurses frustration, increases objectiv-
ity, and fosters collaborative approach to patients care.
Before discharge, refer patient to case manager who can help
patient become involved in informal community programs, such as
volunteer, foster grandparents, or religious groups, to provide peer
and social contact and decrease the patients loneliness and isolation.
Refer patient to a support group. In the context of a group, the
patient may develop a more positive view in the present situation.
Coping Enhancement; Decision-Making Support; Emotional Support;
Environmental Management; Impulse Control Training; Support Sys-
tem Enhancement
Reference
Popejoy, L. (2005, September). Health-related decision-making by older adults
and their families: How clinicians can help. Journal of Gerontological Nurs-
ing, 31(9), 1218.
INEFFECTIVE COMMUNITY COPING

DEFINITION
Pattern of community activities for adaptation and problem-solving
that is unsatisfactory for meeting the demands or needs of the com-
munity
Deficits in participation
Excessive conflicts
Expressed powerlessness and vulnerability
Failure of community to meet its own expectations
High illness rate
Increased social problems (abuse, divorce, and unemployment)
Perception of stressors as excessive
RELATED FACTORS
Deficits in community social Natural disasters
support services Man-made disasters
Deficits in community social Inadequate resources for prob-
resources lem solving
Communication Risk management
Healthcare system
EXPECTED OUTCOMES
Community members will
Express awareness of seriousness of high school adolescent preg-
nancy rate in their community.
Express need for plan to reduce prevalence of teen pregnancy.
Develop and implement plan to reduce teen pregnancy.
Evaluate success of plan in meeting goals and objectives and will
continue to revise it, as necessary.
Report reduction in rate of teen pregnancy.
Community Competence; Community Health Status
Determine: Assess the following: community demographics; number of
teen pregnancies in the community in the past 2 years; attitudes toward
teen mothers and their infants; availability of programs in the schools
that help teen mothers continue their education; teens knowledge about
sex and sexuality; religious attitudes in the community toward sex
and sexuality; influence of religious groups on educators. Assessment
information will be useful in establishing appropriate interventions.
Perform: Collect statistical data from schools to analyze teen
pregnancy rates as a basis for evaluating a pregnancy prevention
91
program. Plan a teen pregnancy program that can be used in
schools. Include information on risks, problems, and complications
of teen pregnancy. Contact local corporations for financial assistance
in supporting educational programs.
Establish clubs for adolescent girls in the community. These can
be used as a method for educating as well as helping girls establish
healthy relationships.
Establish therapeutic relationships with pregnant adolescents to
build support during this difficult period.
Inform: Provide education on birth-control measures (including absti-
nence from sex) and have this information available at school.
Encourage an information campaign to educate adolescents, parents,
and community members about problems related to teen pregnancy.
Teach parent to observe behavioral cues from child. For example,
the child may become fussy when he is ready for a nap or may pull
his ear if he has an earache to indicate that he has pain. Explain the
range of options for responding to these cues in positive ways. Par-
ents may be unfamiliar with cues from child behavior.
Teach parents to give physical care when the need exists. The
parents may need instruction on the importance and proper way of
providing care. Teach relaxation techniques that can be done by the
parents such as guided imagery, progressive muscle relaxation, and
meditation. These measures restore psychological and physical equi-
librium by decreasing autonomic response to anxiety.
Encourage local youth groups and religious and social
organizations to feature guest speakers on pregnancy prevention at
their meetings. Speakers with expertise in the area of teen pregnancy
are better able to provide information that may help teens make
better choices in sexual behavior.
Attend: Encourage community members to establish school-based
clinics that allow teens access to reproductive-system models, preg-
nancy tests, and nonprescription birth-control measures to support
teens who choose to protect themselves from unwanted pregnancy.
Manage: Develop a referral list for teens that includes resources such as
hospitals with human sexuality courses, charities that provide prenatal
care and childbirth services, womens clinics, and Planned Parenthood
to compensate for restricted access to information in the schools.
Community Health Development; Health Education; Health Screen-
ing; Program Development
Reference
Brindis, C. D. (2006). A public health success: Understanding policy changes
related to teen sexual activity and pregnancy. Annual Review of Public
Health, 27, 277295.
READINESS FOR ENHANCED COPING

DEFINITION
A pattern of cognitive and behavioral efforts to manage demands
that is sufficient for well-being and can be strengthened
Defines stressors as manageable
Seeks knowledge of new strategies
Seeks social support
Uses a broad range of problem-oriented and emotion-oriented
strategies
Uses spiritual resources
Coping
EXPECTED OUTCOMES
The patient will
Identify major issues that require ongoing enhancement of coping
strategies.
Express feelings associated with coping strategies.
Demonstrate readiness to develop enhanced strategies.
Identify support persons and activities that will assist in goal
attainment.
Coping; Quality of Life
Determine: Assess patients usual coping mechanisms, roles and
responsibilities, social support, spiritual resources, and use of alcohol
and tobacco in order to decide on a focus for interventions.
Perform: Establish a trusting relationship with patient by spending
time with the patient each shift, which will encourage the patient to
be more honest and open.
Begin discussions at patients level of comfort. If patient wants to
express anger or other emotion, listen carefully. Until the patient has
had an opportunity to talk, you will not be able to move him to a
place where the issue can be discussed logically.
Inform: Provide information on informed consent because parents
will be making decisions for the childs care.
Teach additional skills that enhance coping strategies. Help the
patient develop a program by using relaxation strategies (i.e., medi-
tation, guided imagery, yoga, exercise); these strategies will help to
reduce anxiety and allow the patient to concentrate.
Teach problem-solving skills. Have patient role-play to
demonstrate how to set up options and choose from among them.
93
Attend: Encourage patient to continue adhering to his plan for
enhanced coping strategies. Compliance with the plan will produce
results for the patient. It will also help patient measure success.
Encourage patient to continue involvement in a wide range of
activities. More activities will involve more choices.
Encourage patient to look for volunteer opportunities in the com-
munity as a way of keeping the patient involved with others.
Offer to meet with patient regularly, if desired, to help patient
continue developing enhanced coping skills.
Manage: Refer patients to support groups and offer ideas about edu-
cational opportunities in the community.
Active Listening; Coping Enhancement
Reference
Fiks, A. G., et al. (2006, December). Identifying factors predicting immuniza-
tions delay for children followed in an urban primary care network using
an electronic health record. Pediatrics, 118(6), 16801686.

COMMUNITY COPING
DEFINITION
Pattern of community activities for adaptation and problem solving
that is satisfactory for meeting the demands or needs of the commu-
nity but can be improved for management of current and future
problems/stressors
Active planning to handle predicted stressors
Active problem solving when faced with stressors
Agreement that community carries responsibility for stress manage-
ment
Positive communication among community members and between
community members and larger organizations
RELATED FACTORS
One or more characteristics that indicate effective coping:
Acknowledges power Defines stressors as manageable
Aware of possible environmen- Seeks knowledge of new
tal changes strategies
Communication Populations
Coping Risk management
EXPECTED OUTCOMES
Community members will
Express understanding of problems associated with failure to
immunize population and will recognize the needs to reduce the
number of adults and children who are not immunized.
Initiate a plan to increase the number of immunizations in popula-
tion and provide adequate protection from communicable diseases.
Work to reduce spread of communicable diseases and increase the
number of immunizations.
Evaluate established plans for ensuring that all children become
immunized, and will make changes to plans as needed.
Community Competence; Community Health Status: Immunity;
Community Risk Control: Communicable Disease
Determine: Assess community members level of understanding of the
importance of immunization. If level of compliance is low, survey
community needs to determine why. Determine ease of access in the
community for members to comply with immunization
requirements/needs. Identify new members of the community, such
as immigrants or refugees. This assessment will assist in identifying
appropriate intervention.
95
Perform: Collect statistical data from community health sources,
such as the health department and schools to continue to identify
children who have not been immunized. Recruit local agencies with
an adequate number of professionals able to deliver the immuniza-
tion services.
Contact parents personally or by handwritten note about children
who have not been immunized. Make it clear to the parents that
your purpose is to protect the children.
Inform: Provide extensive educational opportunities in the
community about communicable diseases and the importance of
immunization. Educate persons in the community in their first lan-
guage to ensure adequate understanding.
Attend: Encourage community members to implement a program to
disseminate information about problems associated with inadequate
immunization to educate residents and promote the communitys
established immunization program.
Encourage health departments, clinics, and practitioners offices to
provide information on the recommended childhood immunization
schedule to the public to foster understanding about the importance
of educating the public.
Conduct a follow-up survey on immunization rates to measure the
effectiveness of educational initiatives.
Manage: Supply a list of referrals for the parents of children who
are not immunized. Include information on low-cost health
insurance, city health centers, and well-baby clinics to encourage
compliance. Helping the parents by giving referrals will empower
them to meet their child's health care needs.
Communicable Disease Management; Community Health Develop-
ment; Health Education; Health Policy Monitoring; Immunization/
Vaccination Management
Reference
Pender, N. J., Murdaugh, C., et al. (2006). Health promotion in nursing prac-
tice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

FAMILY COPING
DEFINITION
Effective management of adaptive tasks by family member involved
with the clients health challenge, who now exhibits desire and
readiness for enhanced health and growth in regard to self and in
relation to the client
Individual expresses interest in making contact with others who
have experienced a similar situation.
Family member attempts to describe growth impact of crisis.
Family member moves in direction of enriching lifestyle.
Family member moves in direction of health promotion.
Individual chooses experiences that optimize wellness.
RELATED FACTORS
Adaptive tasks effectively addressed to enable goals of self-
actualization to surface
Needs sufficiently gratified to enable goals of self-actualization
Behavior Emotional status
Coping Roles/responsibilities
EXPECTED OUTCOMES
Family members will
Discuss the impact of patients illness and feelings about it with
healthcare professional.
Participate in treatment plan.
Establish a visiting routine beneficial to the patient.
Demonstrate the care needed to maintain patients health status.
Identify and use available support systems.
CaregiverPatient Relationship; Caregiver Well-Being; Family
Coping; Family Normalization; Health-Promoting Behavior
Determine: Assess normal pattern of communication among family
members; understanding and knowledge of family members about
patients condition; familys past response to crises; patients percep-
tion of health problem. Assess patient and familys spiritual needs,
including religious beliefs and affiliation. Assessment of these factors
will assist in selecting appropriate interventions.
Perform: Schedule time to meet with family and patient in order to
listen to ways in which they plan to enhance their coping skills in
the present situation.
Provide comfort measures such as bathing, massage, regulation of
environmental temperature, and mouth care, according to the
97
patients needs and preferences. Comfort can promote ability to
cooperate with the plan.
Establish a visiting schedule that will not tax patients or familys
resources. Use patients daily routine to aid in planning (e.g., no vis-
iting during treatments or during periods of uninterrupted rest).
Establishing a routine will allow the patient have consistency and a
measure of control.
Inform: Teach self-healing techniques to patient and family such as
meditation, guided imagery, yoga, and prayer. These strategies pro-
mote anxiety reduction.
Teach patient how to incorporate the use of self-healing
techniques in carrying out usual daily activities in order to encour-
age ongoing use of the strategies.
Demonstrate procedures and encourage participation in patients
care in a way that maximizes patients comfort. Both patient and
family need to work together to implement the plan with patients
comfort in mind.
Provide patient with concise information about condition. Be
aware of what family members already know. Honesty is important
when conveying information.
Attend: Reinforce familys efforts to care for patient. Let family
know they are doing well to ease adaptation to new caregiver roles.
Ensure privacy for patient and family visits to foster open
communication.
Encourage family to support patients independence. Encourage
patients cooperation as you continue with healing techniques, such
as therapeutic touch. There is a need to allow for as much independ-
ence on the part of the patient as possible. At times the family will
try to promote dependency to the detriment of the patient.
Provide emotional support to family by being available to answer
questions. Availability will communicate to the family that you are
concerned for them and the patient.
Manage: Refer family to community resources and support groups
available to assist in managing patients illness and providing emo-
tional and financial assistance to caregivers.
Coping Enhancement; Family Process Management
Reference
Nelson, J. E., et al. (2005, March). When critical illness becomes chronic: Infor-
mational needs of patient and family. Journal of Critical Care, 20(1), 7989.
RISK FOR SUDDEN INFANT

DEATH SYNDROME
DEFINITION
Presence of risk factors for an infant under 1 year of age
RISK FACTORS
Modifiable Consistent disorientation to
Delayed prenatal care environment
Infant overheating Partially Modifiable
Infant over wrapping Low birth weight
Infants placed to sleep in a Prematurity
prone position Young maternal age
Infants placed to sleep in side- Nonmodifiable
lying position Ethnicity
Lack of prenatal care Male gender
Postnatal infant smoke expo- Seasonality of sudden infant
sure death syndrome (SIDS) (winter
Prenatal infant smoke and fall)
Soft underlayment (loose arti- Infant age of 24 months
cles in the sleep environment)
Sleep/rest
Roles/responsibilities
Values/beliefs
EXPECTED OUTCOMES
The parents will
Be receptive to teaching and guidance.
Verbalize understanding of risk factors and provide all precautions
possible to prevent disorder.
Verbalize feelings of preparedness and ability to handle emergen-
cies utilizing CPR techniques and services.
Exhibit appropriate coping skills in dealing with high-risk infant.
The infant will
Sleep alone in a crib on a firm sleep surface.
Maintain normal body temperature as indicated by apnea monitor
worn during sleep.
Knowledge Infant Care; Knowledge Parenting; Parent Performance;
Risk Control; Risk Detection
Determine: Assess prenatal history; maternal history; parental experi-
ence; monitor heart rate, blood pressure; respiratory rate, quality,
depth of respirations, breath sounds; reflexes, response to touch. The
assessment information will assist in identifying appropriate
interventions.
99
Perform: Position infant on back when placed in the crib. Incidence
of SIDS is higher when infant is placed in a prone position.
Elevate infants head slightly when placed in the crib to decrease
abdominal pressure on diaphragm and allow better expansion of lungs.
Place infant on a firm sleep surface to prevent him or her from
sinking into the mattress cover or blanket.
Maintain room at appropriate temperature and avoid wrapping
the infant in heavy blankets. Excessive heat has been identified as a
possible risk factor.
Inform: Educate parents about risk factors of SIDS because modifica-
tion of current practices can reduce risk and prevent occurrence.
Instruct caregivers on ways to maintain a safe environment in the
home. Provide written information to caregivers on all important
aspects of the infants care.
Teach parents to avoid having loose blankets, toys, or other arti-
cles in the crib to decrease risk of accidental suffocation.
Encourage mother to breast-feed because there is a lower
incidence of SIDS in babies who are breast-fed.
Teach parents how to correctly apply leads and set alarms of the
apnea monitor. The benefit of the monitor can be achieved only if it
is used correctly.
Instruct parents in CPR to reduce anxiety and promote confidence
in performing correct technique. Allow time for return
demonstrations to prepare parents to cope with infant when he or
she returns home.
Attend: Encourage parents in their efforts to care for the infant. Pro-
vide suggestions for coping mechanisms to help reduce the anxieties
associated with caring for a high-risk infant. Be aware that parents
may be sensitive to your unspoken feelings about the situation.
Encourage parents to interact with other parents managing high-
risk infants well. Peer support may help to reduce fear in the parents.
Involve parents in planning and decision making for their infant.
Investment in decision making will promote compliance with the plan.
Manage: Refer to case manager/social worker/home health agency to
ensure that parents receive adequate support in caring for the infant.
Refer parents to support group if one is available.
Family Support; Infant Care; Risk Control
Reference
Thogmartin, J. R., et al. (2001). Sleep position and bed-sharing in sudden
infant deaths and examination of autopsy findings. Journal of Pediatrics,
138(20), 212217.

DECISION MAKING
DEFINITION
A pattern of choosing courses of action that is sufficient for meeting
short- and long-term health-related goals and can be strengthened
Expresses desire to enhance decision making
Expresses desire to enhance congruency of decisions with personal
values and goals
Expresses desire to enhance congruency between decisions and
sociocultural goals and values
Expresses desire to enhance riskbenefit analysis of decisions
Expresses desire to enhance the understanding of choices
Coping Knowledge
EXPECTED OUTCOMES
The patient will
Express the desire to make effective decisions.
Verbalize decision-making goals and concerns.
Discuss measures used to evaluate decisions.
Make decisions that promote maximal physical, mental, social,
and psychological well-being.
Involve family, friends, and clergy in healthcare decision making
when appropriate.
Decision Making; Participation in Healthcare Decisions; Self-Care:
IADLs
Determine: Assess usual coping strategies employed by the patient
when making decisions; determine how the patient goes about mak-
ing difficult decisions; have the patient describe several challenging
decisions he or she made in the past year. Assessment information
will help identify appropriate interventions.
Evaluate support systems available to the patient when it is neces-
sary to make decisions. Patients often need support of families or
other support systems when they are faced with major decisions.
Perform: Provide assistance with ADLs as required. As the patient
receives assistance, it is important to allow him or her to be as inde-
pendent as possible.
Make changes in the environment to reduce unnecessary stimula-
tion and promote a sense of calm.
Inform: Teach patient simple decision-making techniques and role-
play the same. Return demonstration from the patient will give
101
him or her confidence that he or she can choose wisely among
options.
Educate family about the importance of allowing the patient to
think and act for himself or herself in order to give the patient a
sense of control over the present situation.
improve patients confidence in his or her ability to make logical
decisions.
Provide patient with all necessary support during hospitalization
to prepare him and his family to continue the process of having the
patient make decisions about his own care.
ity to participate will encourage greater compliance with the treat-
ment plan.
Manage: If patient continues to have difficulty, refer to case
manager/social worker/mental health professional for continued
follow-up.
Provide appropriate assistance to the family members when they
are trying to provide; it might be helpful in working with the
patient.
Decision-Making Support; Health System Guidance; Self-Responsibility
Facilitation
Reference
Moser, A., et al. (2007, February). Patient autonomy in nurse-led shared care:
A review of theoretical and empirical literature. Journal of Advanced Nurs-
ing, 57(4), 357365.
INEFFECTIVE DENIAL
DEFINITION
Conscious or unconscious attempt to disavow the knowledge or
meaning of an event to reduce anxiety/fear, but leading to the detri-
ment of health
Delay in seeking or refusal of medical attention to detriment of
health
Displacement of fear about conditions impact
Displacement of sources of symptoms to other organs
Failure to perceive personal relevance or danger of symptoms
Inability to admit impact of disease on life pattern
Inappropriate affect
Minimization of symptoms
Refusal to admit fear of death or invalidism
RELATED FACTORS
Anxiety Lack of control of the situation
Fear of death Overwhelming stress
Fear of loss of autonomy Threat of unpleasant reality
Behavior Coping
EXPECTED OUTCOMES
The patient will
Describe knowledge and perception of present health problem.
Describe life pattern and report any changes.
Express knowledge of stages of grieving.
Demonstrate behavior associated with the grief process.
Indicate, either verbally or through behavior, an increased aware-
ness of reality.
Acceptance: Health Status; Anxiety Level; Coping; Fear Self-Control;
Health Beliefs: Perceived Threat; Symptom Control
Determine: Assess patients understanding and perception of present
health state, including awareness of diagnosis, and perception of rel-
evance on life pattern and description of symptoms.
Evaluate coping status and mental status, including mood, affect,
memory, and judgment. Assessment of these factors will help iden-
tify appropriate interventions.
Perform: Schedule a specific amount of uninterrupted non-care-
related time each day with the patient to allow patient to express
feelings and concerns.
103
Assist patient with ADLs as needed to conserve energy and avoid
overexertion. Assist with grooming (e.g., shaving for men, hair and
makeup for women). Offer massage to enhance comfort and
promote relaxation.
Encourage active exercise (e.g., provide a trapeze or other assistive
device if needed). Exercise will promote positive attitude.
Inform: Discuss stages of anticipatory grieving to increase
understanding of what is happening and increase patients ability to
cope.
Teach patient about diagnosis and treatment as he or she demon-
strates readiness to learn. Provide brochures and simple written
materials to help with the learning process.
improve patients self-concept and motivate the patient to be more
involved in planning care.
for treatment.
Schedule treatments apart from visiting to allow for periods of
rest.
Maintain frequent discussions with physicians and staff to be cer-
tain what patient has been told by other care providers.
Manage: Refer to case manager/social worker for follow up care.
Refer to clergy person for spiritual care if patient expresses interest.
Anxiety Reduction, Behavior Modification; Calming; Counseling;
Decision-Making Support; Truth Telling
Reference
Telford, K., et al. (2006, August). Acceptance and denial: Implications for
Nursing, 55(4), 457464.
IMPAIRED DENTITION
DEFINITION
Disruption in tooth development and eruption patterns or structural
integrity of individual teeth
Caries; extractions; evidence of periodontal disease
Evulsion
Inability or unwillingness of parents or caregiver to provide child
with dental care; lack of access to dental care
Lack of knowledge of appropriate dental hygiene practices
Malocclusion; plaque; toothache
Loose teeth; premature loss of primary teeth
Erosion of enamel
RELATED FACTORS
Barriers to self-care Ineffective oral hygiene
Bruxism Nutritional deficits
Chronic use of coffee, tea, red Sensitivity to cold
wine, tobacco Sensitivity to heat
Chronic vomiting
Knowledge Roles/responsibilities
Nutrition Values and beliefs
EXPECTED OUTCOMES
The individual will
Brush teeth with minimal supervision.
Demonstrate good brushing technique.
Not show evidence of dental caries, periodontal disease, or maloc-
clusion.
Reduce quantity of cariogenic foods in his or her diet.
Show evidence of good daily oral hygiene.
SUGGESTED NOC OUTCOME
Oral Hygiene; Self-Care: Oral Hygiene
Determine: Assess dental history; primary and secondary tooth devel-
opment; frequency of visits to dentist; frequency of brushing; condi-
tion of the teeth; nutritional status; medications; socioeconomic sta-
tus. Assessment of these factors will help to identify appropriate
interventions.
Perform: Provide tooth brush, toothpaste, and dental floss.
Schedule times for brushing and have patient begin keeping a
record. Keeping a record will promote compliance.
Inform: Teach child principles of good oral hygiene by using teaching
methods appropriate to his age-group to foster compliance.
105
Teach the child and his or her parents or caregiver about the rela-
tionship between diet and dental health. Show the child pictures that
promote good dental health and pictures of foods that lead to den-
tal decay. If the child can read, teach him or her to read labels;
teach him or her to avoid products with excessive sucrose. Sucrose
is a simple sugar that promotes dental decay.
Demonstrate good brushing technique. Stress the importance of
having teeth feel clean rather than the need to follow a specific pro-
cedure.
Attend: Encourage parents to create a pleasant mealtime environment
with nutritious foods made to look appealing to a child so that the
child will learn to recognize nutritious foods.
Give positive reinforcement for good choices. Be supportive to the
parents as they try to help the child modify diet to include more
nutritional foods. It is not easy to teach children to make right food
choices, and parents benefit from encouragement to keep reinforcing
good healthy choices.
Encourage ample fluid intake to keep gums well hydrated.
Adequate fluids promote healthy gums.
Manage: Refer to dentist for assessment of dental health.
Schedule a follow-up appointment with parents to ensure they
have taken child to the dentist.
Where it is indicated, refer to a nutritionist for help in modifying
diet.
Oral Health Maintenance; Oral Health Promotion; Teaching:
Individual
Reference
Melvin, C. S. (2006, JanuaryFebruary). A collaborative community based
oral care program for school age children. Clinical Nurse Specialist, 20(1),
1822.
RISK FOR DELAYED DEVELOPMENT

DEFINITION
At risk for delay of 25% or more in one or more of the areas of
social or self-regulatory behavior, or in cognitive, language, gross or
fine motor skills
RISK FACTORS
Adopted child Hearing impairment
Behavior disorders Inadequate nutrition
Brain damage Genetic disorders
Chemotherapy Lead poisoning
Chronic illness Substance abuse
Congenital disorders Vision impairment
Failure to thrive Poverty
Foster child Violence
Coping Roles/relationship
Communication Values/beliefs
Emotional
EXPECTED OUTCOMES
The child will
Continue to grow and gain weight in accordance with growth
chart of age and sex.
Consume _____ calories and ________ ml of fluids representing
________ servings (specify for each food group).
Participate in activities and be provided with a supervised, uncon-
fined environment that includes age-appropriate toys and fosters
interaction with childs development.
The parents will
Express understanding of measures to reduce childs risk for
delayed development.
Identify risk factors that may interfere with childs development.
Family Functioning; Growth; Parenting Performance; Personal
Health Status; Risk Control
Determine: Assess familys developmental stage; family roles; family
rules; socioeconomic status; family health history; history of substance
abuse; history of sexual abuse of spouse or children; problem-solving
and decision-making skills; religious affiliation; ethnicity. Assessment
information will aid in developing a workable plan of care.
Perform: Weigh and measure child. Review growth chart to establish
current height and weight values.
Establish a meal program to meet the childs nutritional needs.
107
Create an environment in which family members can express
themselves openly and honestly. Establish rules for communication
during meetings with the family. Having rules allows everyone to
participate and keep the discussion on the designated topic.
Inform: Teach parents about nutritional requirements needed for
child of specific weight and age. Discuss various meal choices avail-
able to the child. Providing instruction in writing simplifies the par-
ents role in selecting healthy foods.
Educate parents about childs need for quality interaction with
family members and others. Inform parents about age-appropriate
activities and toys as well as potential playmates for a child of spe-
cific age. Emphasize importance of providing an unconfined, super-
vised environment in which the child can play to encourage play
that encourages the child to move freely.
Educate parents about risk factors that may lead to delayed devel-
opment, such as lack of supportive interactions or age-appropriate
activities. The ability to recognize risk factors will promote getting
help for the parents and child sooner.
Teach coping skills to parents to enable them to deal effectively
with the childs needs.
Attend: Encourage parents to listen to the child and communicate in
a loving, supportive way in order to allow the child to maintain a
positive attitude.
Encourage parents to identify preventive measures they may initi-
ate at home to ensure continuity of care. Consistency in providing
care will help the child understand that the plan carries over to all
aspects of his or her life.
Manage: Provide parents with a copy of childs teaching plan. This
helps to reinforce what the child is learning.
Refer to case manager/social worker to ensure that a home assess-
ment is done.
Refer to nutritionist for follow-up with food issues.
Nutrition Management; Family Process Maintenance; Coping
Enhancement; Family Integrity Promotion; Maintenance; Normaliza-
tion Promotion; Substance Use Prevention; Substance Use Treatment;
Risk Identification
Reference
Moss, J. (2005, March). Development of a functional ability scale for children
and young people with myalgic encephalopathy (ME)/chronic fatigue syn-
drome (CFS). Journal of Child Health Care, 9(1), 2030.
DIARRHEA
DEFINITION
Passage of loose, unformed stools
Abdominal pain and cramping
At least three loose, liquid stools per day
Hyperactive bowel sounds
Urgency
RELATED FACTORS
Psychological: anxiety, high stress levels
Physiological: malabsorption, infectious processes, irritation, para-
sites, inflammation
Situational: adverse effects of medications, alcohol abuse,
toxins, laxative abuse, contaminants, radiation, tube feedings,
travel
Coping Fluid and electrolytes
Emotional Nutrition
Elimination
EXPECTED OUTCOMES
The patient will
Have less or no diarrheal episodes.
Resume usual bowel pattern.
Maintain weight and fluid and electrolyte balance.
Keep skin clean and free from irritation or ulcerations.
Explain causative factors and preventive measures.
Discuss relationship of stress and anxiety to episodes of diarrhea.
State plans to use stress-reduction techniques (specify).
Demonstrate ability to use at least one stress-reduction technique.
Bowel Continence; Hydration; Symptom Control
Determine: Monitor and record frequency and characteristics of
stools to monitor treatment effectiveness.
Identify stressors and help the patient solve problems to provide
more realistic approach to care.
Monitor perianal skin for irritation and ulceration; treat according
to established protocol to promote comfort, skin integrity, and free-
dom from infection.
Perform: Administer antidiarrheal medications, as ordered, to
improve body function, promote comfort, and balance body fluids,
salts, and acidbase levels. Monitor and report effectiveness of
medication.
109
Provide replacement fluids and electrolytes as prescribed. Maintain
accurate records to ensure balanced fluid intake and output.
Inform: Teach patient to use relaxation techniques to reduce muscle
tension and nervousness; recognize and reduce intake of diarrhea-
producing foods or substances (such as dairy products and fruit) to
reduce residual waste matter and decrease intestinal irritation.
Instruct patient to record diarrheal episodes and report them to
staff to promote comfort and maintain effective patientstaff
communication.
Attend: Encourage patient to ventilate stresses and anxiety; release of
pent-up emotions can temporarily relieve emotional distress.
Encourage and assist patient to practice relaxation techniques to
reduce tension and promote self-knowledge and growth.
Spend at least 10 min with patient twice daily to discuss stress-
reducing techniques; this can help patient pinpoint specific fears.
Manage: Consult with dietician to determine foods that may be
related to diarrheal episodes.
Diarrhea Management; Nutrition Management; Skin Surveillance;
Weight Management
Reference
Fletcher, P. C., & Schneider, M. A. (2006, SeptemberOctober). Is there any
food I can eat? Living with inflammatory bowel disease and/or irritable
bowel syndrome. Clinical Nurse Specialist, 20(5), 241247.
RISK FOR COMPROMISED HUMAN DIGNITY

DEFINITION
At risk for perceived loss of respect and honor
Cultural incongruity
Disclosure of confidential information
Exposure of the body
Inadequate participation in decision making
Loss of control of bodily functions
Perceived dehumanizing treatment
Perceived humiliation
Perceived invasion of privacy
Use of undefined medical terms
Behavior Coping
EXPECTED OUTCOMES
The patient will
Express satisfaction with level of respect.
Identify those things that will reduce feelings of powerlessness and
vulnerability and increase perception of autonomy.
The patient and family will
Agree on a plan to protect patients privacy and respect patients
confidentiality; family members will evaluate the progress they are
making in protecting the patients right to confidentiality.
Express satisfaction with the level of respect shown to patients
human dignity.
Client Satisfaction; Protection of Rights; Coping; Personal
Autonomy; Self-Esteem
Determine: Assess patients perception of the current health problem
and problem-solving techniques he or she uses to cope. Determine
level of family involvement and support. Ask about support systems,
including family, friends, and clergy. Determine patients legal status,
including the authority to give consent for treatments or procedures.
Assessment of these factors will assist in identifying appropriate
interventions.
Perform: Schedule time to spend with the patient to listen to
concerns and feelings about current situation.
Develop a plan visiting with patient to ensure that the desirable
level of privacy is being maintained.
111
Incorporate questions into discussions with the patient that are
open-ended, and start with such words as what, how, and
could, rather than why. Open-minded, nonthreatening question-
ing encourages the patient to discuss issues of concern and improve
ability to articulate what he or she desires.
Schedule team meetings with staff to ensure that communication
with the patient is consistent and truthful.
Inform: Provide education on legal and ethical rights of the patient
to have his human dignity respected, as well as the hospitals or
agencys policies on respecting the rights of patients. Include family
in this process. Every patient is entitled to have a copy of the hospi-
tals Bill of Patients Rights.
Arrange a team conference with the staff to review with patient
and family information on bioethics and moral rights of patients.
Role model or provide case studies with situations to allow staff to
design strategies for handling difficult issues associated with patients
rights.
Attend: Encourage discussion of thoughts and feelings about the
overuse of negative expressions on the part of the patient by
suggesting strategies such as a rubber band on the wrist to snap
every time negative expressions begin. Negative expressions can
impair the patients progress toward a healthy lifestyle.
Encourage role-playing of verbal and nonverbal communication
techniques in a safe environment to enhance communication skills.
Provide support through active listening, appropriate periods of
silence, reflection on feelings, and paraphrasing and summarizing
comments. Active listening techniques encourage patient
participation in communication.
Make sure that patient has clear explanations for everything that
will happen to him. Ask for feedback to ensure that patient under-
stands. Anxiety may impair patients cognitive abilities.
Manage: Refer patient and/or family to a support network that will
relate to them in regards to caregiving, the pressures of illness, and
other issues related to respecting human dignity. A support network
will provide an outlet for the family members as they work through
the various issues.
Body Image Enhancement; Self-Awareness Enhancement; Self-Esteem
Enhancement
Reference
Coventry, M. L. (2006, May). Care with dignity: A concept analysis. Journal
of Gerontological Nursing, 32(5), 4248.
MORAL DISTRESS
DEFINITION
Response to the inability to carry out ones chosen moral/ethical
decision/action
Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety,
self-doubt, fear) over difficulty acting on moral choice
RELATED FACTORS
Conflict among decision makers Loss of autonomy
Conflicting information guiding Physical distance of decision
ethical and/or moral decision maker
making Time constraints for decision
Cultural conflicts making
Decisions involving end-of-life Treatment decisions
matters
Roles/relationship Coping
EXPECTED OUTCOMES
The patient and family will
Understand medical diagnosis, treatment regimen, and limitations
related to extent of illness.
Identify ethical/moral dilemma.
Describe personal and family values and conflict with current situ-
ation.
Identify healthcare ethics resources to assist in resolution of con-
flict.
Verbalize relief from anguish, uneasiness, or distress.
Acceptance: Health Status; Client Satisfaction; Communication;
Decision Making; Family Integrity; Family Functioning; Family
Health Status; Family Integrity; Knowledge; Spiritual Health
Interventions and Rationales
Determine: Assess patients and familys understanding of the diagno-
sis and prognosis, limitations, treatment options; description of their
personal values; and their physical expressions of suffering. Assess-
ment factors assist in identifying appropriate interventions.
Perform: Establish an environment in which family members can
share comfortably and openly their issues and concerns.
Enlist assistance of healthcare ethics resources such as ethics com-
mittee or consultants. Including experts in healthcare ethics will
assist in identifying the patient/family values and reason for the
113
dilemma. By identifying the source of the conflict, the process of
resolution may begin, thus leading to better understanding by all
parties and partial or full relief from moral suffering.
Enlist assistance of chaplain or personal clergy to assist in the
process of resolution through clarification of values related to
religious views. Chaplains and personal clergy may provide a more
neutral third party that can help defuse the situation. Personal
trusted clergy might recognize or facilitate patient/family verbal and
physical expressions of suffering or relief.
Inform: Educate patient and family about medical diagnosis,
treatment regimen, and limitations involved in to help both patient
and family understand the limits of and read on for medical treat-
ment related to medical diagnosis.
Attend: Provide or set aside ample time for patient and family to
express their feelings about the current situation. Open, honest com-
munication may clear misconceptions on both sides and facilitate
relief from suffering in the mid of dilemma.
Acknowledge ethical/moral position of the patient/family who may
feel that their positions or views will go unrecognized in the mid of
serious illness and high-tech treatments; they may not want to
bother nurses and physicians with these concerns. Acknowledging
their concerns, values, and moral position allows for holistic care.
Manage: Refer, where requested, for follow-up for a family member
who needs exercise, weight management, diet assistance, health
screenings, and so forth. Assisting patient to make referrals will help
ensure continued efforts on the part of the patient to live a healthier
lifestyle.
Active Listening: Anger Control Assistance; Anxiety Reduction; Con-
flict Mediation; Consultation; Counseling; Documentation; Family
Integrity Promotion; Family support; Multidisciplinary Care Confer-
ence; Spiritual Support Family Support; Family Integrity Promotion;
Family Maintenance; Truth Telling
Reference
Kopala, B., & Burkhart, L. (2005). Ethical dilemma and moral distress: Pro-
posed new NANDA diagnosis. International Journal of Nursing Terminolo-
gies and Classifications, 16(1), 313.
RISK FOR DISUSE SYNDROME

DEFINITION
At risk for deterioration of body systems as the result of prescribed
or unavoidable musculoskeletal inactivity
RISK FACTORS
Altered LOC Prescribed immobilization
Mechanical immobilization Severe pain
Paralysis
Activity/exercise Neurocognition
Elimination; nutrition Tissue integrity
EXPECTED OUTCOMES
The patient will
Have no evidence of altered mental, sensory, or motor ability.
Have no evidence of thrombus formation or venous stasis.
Have no evidence of decreased chest movement, cough stimulus,
depth of ventilation, pooling of secretions, or signs of infection.
Maintain normal bowel elimination patterns.
Maintain adequate dietary intake, hydration, and weight.
Have no evidence of urine retention, infection, or renal calculi.
Maintain muscle strength and tone and joint ROM.
Have no evidence of contractures or skin breakdown.
Maintain normal neurologic, cardiovascular, respiratory, GI, nutri-
tional, genitourinary, musculoskeletal, and integumentary function-
ing during period of inactivity.
Coordinated Movement; Endurance; Immobility Consequences: Phys-
iological; Immobility Consequences: Psychocognitive; Mobility; Risk
Control
Determine: Inspect skin every shift and follow facility policy for pre-
vention of pressure ulcers to prevent or mitigate skin breakdown.
Administer anticoagulant therapy, if ordered; monitor for signs and
symptoms of bleeding. Anticoagulant therapy may cause hemorrhage.
Monitor vital signs every 4 hr: Monitor breath sounds and respi-
ratory rate, rhythm, and depth to rule out respiratory complications.
Monitor arterial blood gas levels or pulse oximetry to assess
oxygenation, ventilation, and metabolic status.
Monitor urine characteristics and patients subjective complaints
typical of UTIs, such as burning, frequency, and urgency. Obtain urine
cultures, as ordered. These measures aid early detection of UTI.
115
Identify functional level to provide baseline for future assessment,
and encourage appropriate participation in care to prevent complica-
tions of immobility and increase patients feelings of self-esteem.
Perform: Avoid positions that put prolonged pressure on body parts
and compress blood vessels; reposition patient at least every 2 hr
within prescribed limits. These measures enhance circulation and
help prevent tissue or skin breakdown.
Use pressure-reducing or pressure-equalizing equipment, as
indicated or ordered (flotation pad, air pressure mattress, sheepskin
pads, or special bed). This helps prevent skin breakdown by reliev-
ing pressure.
Apply antiembolism stockings; remove for 1 hr every 8 hr. Stock-
ings promote venous return to heart, prevent venous stasis, and
decrease or prevent swelling of lower extremities.
Suction airway, as needed and ordered, to clear airway and stimu-
late cough reflex. Note secretion characteristics.
Provide small, frequent meals of favorite foods to increase dietary
intake. Increase fiber content to enhance bowel elimination. Increase
protein and vitamin C to promote wound healing; limit calcium to
reduce risk of renal and bladder calculi.
Perform active or passive ROM exercises at least once per shift.
Teach and monitor appropriate isotonic and isometric exercises.
These measures prevent joint contractures, muscle atrophy, and
other complications of prolonged inactivity.
Provide or help with daily hygiene; keep skin dry and lubricated
to prevent cracking and possible infection.
Inform: Teach and monitor deep breathing, coughing, and use of
incentive spirometer to help clear airways, expand lungs, and
prevent respiratory complications. Maintain regimen every 2 hr.
Instruct patient to avoid straining during bowel movements that
may be hazardous to patients with cardiovascular disorders and
increased intracranial pressure. Teach to administer stool softeners,
suppositories, or laxatives, as ordered, and monitor effectiveness.
Attend: Encourage fluid intake of 212312 qt (2.53.5 L) daily,
unless contraindicated, to maintain urine output and aid bowel elim-
ination. Encourage patient and family to verbalize frustrations to
help patient and family cope with treatment.
Activity Therapy; Body Mechanics Promotion; Cognitive
Stimulation; Energy Management; Exercise Promotion; Exercise
Therapy: Ambulation; Fluid Management; Nutrition Management
Reference
Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized
elderly. The Canadian Nurse, 101(6), 1620.
RISK FOR DISTURBED MATERNALFETAL

DYAD
DEFINITION
At risk for disruption of the symbiotic maternalfetal dyad as a
result of comorbid or pregnancy-related conditions
Complications of pregnancy (e.g., premature rupture of
membranes, placenta previa or abruption, late prenatal care, multi-
ple gestation)
Compromised O2 transport (e.g., anemia, cardiac disease, asthma,
hypertension, seizures, premature labor, hemorrhage)
Impaired glucose metabolism (e.g., diabetes, steroid use)
Physical abuse
Substance abuse (e.g., tobacco, alcohol, drugs)
Treatment-related side effects (e.g., medications, surgery,
chemotherapy)
RELATED FACTORS
Mental health status Cultural background
Psychosocial issues Fetal well-being
Behavior
Emotional
Roles/relationships
EXPECTED OUTCOMES
The patient will
Be compliant with recommendations for self-care activities to mini-
mize prenatal complications and optimize maternalfetal health.
Verbalize fears and uncertainty related to prenatal condition.
Actively involve significant other/support systems with pregnancy
expectations and plan of care.
Demonstrate the maternal tasks of pregnancy culminating in an
unconditional acceptance of the fetus before delivery.
Prenatal Health Behavior; Knowledge: Pregnancy; Role Performance;
Family Integrity
Determine: At each prenatal visit, assess physical condition,
psychosocial well-being, and cultural beliefs to be able to counsel
and/or refer as needed.
Perform: Encourage support/involvement of significant other(s) dur-
ing course of pregnancy to enhance maternal role adaptation.
Incorporate the cultural beliefs, rites, and rituals of the childbear-
ing family into the plan of care to foster feelings of normalcy with
pregnancy.
117
Inform: Educate patient/significant other on role transition and
maternal tasks of pregnancy to provide anticipatory guidance on
expected psychosocial changes.
Teach trimester-specific risks/danger signs and emphasize
importance of self-monitoring to empower the patient and reduce
potential for adverse fetal effects.
Attend: Encourage patient to express disappointment/concerns
related to relationships, physical condition, and fetal well-being to
promote therapeutic communication.
Manage: Refer to community resources as needed (e.g., prenatal
classes, psychological counseling, pastoral care, social services) to
facilitate appropriate role adaptation.
Anticipatory Guidance; Childbirth Preparation; Coping
Enhancement; Role Enhancement
References
Olds, S., London, M., Ladewig, P., & Davidson, M. (2008). Maternal
newborn nursing and womens health care (8th ed.). Upper Saddle River,
NJ: Prentice-Hall Health.
Ward, S. L., & Hisley, S. M. (2009). Maternalchild nursing care: Optimizing
outcomes for mothers, children, and families. Philadelphia: F.A. Davis Com-
pany.
RISK FOR ELECTROLYTE IMBALANCE

DEFINITION
At risk for change in serum electrolyte levels that may compromise
health
RISK FACTORS
Fluid imbalance (e.g., dehydra- Renal dysfunction
tion, water intoxication) Endocrine dysfunction
Treatment-related side effects Impaired regulatory mechanisms
(e.g., medications, drains) (e.g., diabetes insipidus, syn-
Diarrhea drome of inappropriate
Vomiting antiduretic hormone (SIADH))
Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain electrolyte levels within the normal limits.
Maintain adequate fluid balance consistent with underlying disease
restrictions.
Identify health situations that increase risk for electrolyte
imbalance and verbalize interventions to promote balance.
Verbalize signs and symptoms that require immediate intervention
by healthcare provider.
Remain safe from injury associated with electrolyte imbalance.
Electrolyte & AcidBase Balance, Fluid Balance
Determine: Assess patients fluid status. Patients who demonstrate
fluid volume alterations are likely to have electrolyte alterations as
well.
Monitor patient for physical signs of electrolyte imbalance. Many
cardiac, neurological, and musculoskeletal symptoms are indicative
of specific electrolyte abnormalities.
Perform: Collect and evaluate serum electrolyte results as ordered to
allow for prompt diagnosis and treatment of any abnormalities.
Treat underlying medical condition. Correction of the underlying
cause of electrolyte imbalance is the first step in correcting
electrolyte imbalance.
Inform: Educate patient and family regarding risks for electrolyte dis-
turbances associated with their particular medical condition and pos-
sible interventions if symptoms occur. Early identification and inter-
vention may prevent life-threatening complications of electrolyte
imbalance.
119
Attend: Provide support and encouragement to patient and family in
their efforts to participate in the management of the condition. Pos-
itive feedback will increase self-confidence and feeling of partnership
in care.
Manage: Coordinate care with other members of the healthcare team
to provide safe environment. Electrolyte imbalances can cause poor
coordination, weakness, and altered gait.
Electrolyte Management, Electrolyte Monitoring, FluidElectrolyte
Management
Reference
Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled
water. Journal of Perianesthesia Nursing, 23, 267272.
DISTURBED ENERGY FIELD

Disruption of the flow of energy surrounding a persons being that
results in disharmony of body, mind, and/or spirit
Perceptions of changes in patterns of energy flow, such as changes in
Hearing (tones, words).
Perception of movement (wave spike, tingling, dense, flowing).
Temperature.
Sight (image, color).
RELATED FACTORS
Factors secondary to the slowing or blocking of energy flows may
be as follows:
Maturational (age-related devel- Situational (anxiety, fear, griev-
opmental crisis and/or developing, and pain)
mental [mental] difficulties) Treatment-related (chemother-
Pathophysiologic (illness, apy, immobility, labor & deliv-
injury, and pregnancy) ery, perioperative experience)
Coping Sensation/perception
EXPECTED OUTCOMES
The patient will
Feel increasingly relaxed by slower and deeper breathing, skin
flushing in treated area, audible sighing, or verbal reports of feel-
ing more relaxed.
Visualize images that relax him.
Report feeling less tension or pain.
Use self-healing techniques such as meditation, guided imagery,
yoga, and prayer.
Comfort Level; Health Beliefs; Personal Health Status; Personal
Well-Being; Spiritual Health
Determine: Assess how much support patient desires. Evaluate the
presence of a disorder that is life threatening or requires surgery.
Monitor levels of pain and disorders that may affect the senses.
Assess patients spiritual needs, including religious beliefs and affilia-
tion. Assessment of these areas will help to identify appropriate
interventions.
Perform: Implement measures to promote therapeutic healing. Place
your hands 4 to 6 above the patients body. Pass hands over the
entire skin surface to become intoned to the patients energy fields,
which is the flow of energy that surrounds the human being. Identify
121
areas where there is energy disturbance considering cues such as
cold, heat, tingling, and electric sensation. This technique helps you
become attuned to patients energy field, the flow of energy that sur-
rounds a persons being.
Administer medication as ordered to relieve pain.
breakdown, improve lung expansion, and prevent atelectasis.
Provide comfort measures such as bathing, massage, regulation of
environmental temperature, and mouth care, according to the
patients preferences. Comfort measures done for and with the
patient reduce anxiety and promote feelings of well-being.
Inform: Teach self-healing techniques to both the patient and family
(e.g., meditation, guided imagery, yoga, and prayer). Teach patient
how to incorporate the use of self-healing techniques in carrying out
usual daily activities. It will take repeated use of strategies to induce
a spirit of well-being.
that maximizes his or her comfort. Caregivers may need assistance
with techniques. Lack of skill can cause the patient unnecessary
pain.
Attend: Encourage patients cooperation as you continue with heal-
ing techniques, such as therapeutic touch. Listen for evidence of
effectiveness of treatment by patients statements about reduction in
tension or pain. One treatment rarely restores a full sense of well-
being.
Manage: Refer to mental health specialist or other community agen-
cies as needed. It is important for patient to have ongoing support.
Therapeutic Touch; Discharge Planning; Anxiety Reduction; Pain
Management
Reference
Robb, W. J. (2006, AprilJune). Self-healing: A concept analysis. Nursing
Forum, 41(2), 6077.
IMPAIRED ENVIRONMENTAL
INTERPRETATION SYNDROME
DEFINITION
Consistent lack of orientation to person, place, time, or
circumstances over more than 3 to 6 months necessitating a
protective environment
Chronic confusion
Consistent state of disorientation to environment
Inability to reason, concentrate, or follow simple instructions
Loss of occupation or social function resulting from memory decline
Slow response to questions
RELATED FACTORS
Dementia
Depression
Huntingtons disease
Behavior Knowledge
Communication Sensory perception
EXPECTED OUTCOMES
The patient will
Acknowledge and respond to efforts by others to establish
communication.
Identify physical changes without making disparaging comments.
Remain oriented to the environment to the fullest possible extent.
Remain free from injuries.
The caregiver will
Describe measures for helping the patient cope with disorientation.
Demonstrate reorientation techniques.
Describe ways to make sure that the home is safe for the patient.
Identify and contact appropriate support services for the patient.
Cognitive Orientation; Concentration; Fall-Prevention Behavior;
Memory; Safe Home Environment
Determine: Assess cultural status, functional ability and coordination,
interaction with others in social settings, and presence of vision or
hearing deficits. Assessment of these factors will help in identifying
Perform: Orient patient to reality, as needed: call patient by name;
tell patient your name; provide day, date, year, and place; place a
photograph or patients name on the door; keep all items in the
same place. Consistency and continuity will reduce confusion and
decrease frustration.
123
Place patient in a room near the nurses station to provide imme-
diate assistance from staff, if needed.
Clear patient's room of any hazardous materials, and accompany
patient who wanders to prevent injury.
Work with patient and caregivers to establish goals for coping
with disorientation. Practice with coping skills can prevent fear.
When speaking to the patient, face him and maintain eye contact
to foster trust and communication.
Promote independence while performing ADL measures patient is
unable to perform to reduce feelings of dependence.
Inform: Provide written information to caregivers on reorientation
techniques. Demonstrate reorientation techniques to caregiver to
prepare caregiver to cope with the patient when he or she returns
home.
that maximizes patients potential to encourage patients independence.
Attend: Be attentive to the patient when you are with him. Be aware
that patient may be sensitive to your unspoken feelings about him in
order to inspire confidence in the caregiver.
Help patient and caregivers cope with feelings associated with the
disease. Understanding promotes affective coping.
Have patient perform ADLs. Begin slowly and increase daily, as
tolerated to assist patient to regain independence and enhance self-
esteem. Provide reassurance and praise for completing simple tasks.
Focus on patient's strengths.
Involve caregiver and patient in planning and decision making as
a cooperative effort supports patients needs.
Encourage patient to engage in social activities with people of
all age groups once a week to help relieve the patients sense of
isolation.
Manage: Refer patient to case manager/social worker to ensure
that patient receives longer term assistance to ensure continued
care.
Refer caregiver to a support group. Caregivers need continuous
support from others to cope with the need to provide constant
supervision to the patient.
Anxiety Reduction; Behavior Management; Dementia Management;
Emotional Support; Mood Management; Reality Orientation
Reference
Patton, D. (2006). Reality orientation: Its use and effectiveness within older
person health care. Journal of Clinical Nursing, 15(11), 440449.
ADULT FAILURE TO THRIVE

DEFINITION
Progressive functional deterioration of a physical and cognitive
nature. The individuals ability to live with multisystem diseases,
cope with ensuing problems, and manage his/her care are remarkably
diminished
Cognitive decline, as evidenced by problems with responding
appropriately to environmental stimuli and decreased
perception
Consumption of limited to no food at most meals (i.e., consumes
less than 75% of normal replacements); weight loss
Decreased participation in ADLs that were once enjoyed
Decreased social skills or social withdrawal
Difficulty performing simple self-care tasks
Frequent exacerbations of chronic health problems, such as pneu-
monia or urinary tract problems
Neglect of home environment or financial responsibilities
Adequate elimination pattern for age
RELATED FACTOR
Depression
Knowledge Nutrition
Coping Sleep patterns
Emotional Values and beliefs
EXPECTED OUTCOMES
The patient will
Express understanding of causes of failure to thrive.
Express realization that he or she is depressed.
Consume sufficient amounts of food and nutrients.
Sleep for ___ hours without interruption.
Gain weight.
Verbalize feelings of safety.
Follow up with psychiatric evaluation/social service assistance.
Nutritional Status: Physical Aging Status; Psychosocial Adjustment:
Life Change; Will to Live
Determine: Assess daily food intake; meal preparation; sleep
patterns; mobility status; education, activity, and exercise;
religious affiliation; involvement in social activities; and access to
transportation. Assessment factors will help identify appropriate
interventions.
125
Monitor fluids and electrolytes. Imbalance can be life-threatening.
Perform: Record daily weights at the same time each day to provide
consistent information.
Report abnormal electrolyte levels to ensure that therapy will
reverse and levels will not deteriorate.
Monitor fluid intake and output every 8 hr to ensure that fluids
are balanced. Imbalance can lead to heart failure or dehydration.
Record amount of food consumed and supplements given to
patient to ensure that the patient is getting sufficient nutrition.
Plan activities and exercise consistent with patients capabilities. It
is important that the patient be able to enjoy activity. Overexertion
can lead to cardiac problems.
Arrange for social interaction with other patients. Arrange for the
nurse to spend several short periods of uninterrupted time with the
patient each day to instill trust and a sense of caring.
Teach caregiver how to make meals that may be appetizing to the
patient. Encourage caregiver to record food consumed by patient.
Appetizing foods may help motivate the patient to eat when he or
she claims not to be hungry.
Attend: Create a pleasant mealtime environment for patient. Provide
unlimited access to nourishing foods and nutritional supplements.
Attempt to accommodate ethnic food preferences. This will encour-
age patient when he or she is hungry rather than when food is put
in front of him or her.
Encourage family members and caregivers to establish a plan for
addressing patients failure to thrive in order to take responsibility
for meeting the patients needs to the extent they are able.
Encourage patient to participate in active exercise during the day
to the extent he or she is able. Exercise is essential to a feeling of
well-being.
Manage: Refer patient and family to appropriate agencies in the
community such a meal programs, senior support/activities groups,
and so forth. This kind of follow-up will ensure that the plan has a
chance of succeeding.
Refer patient and family to social services for appropriate resources.
Refer to clergy person for spiritual help if patient wishes.
Coping Enhancement; Home Maintenance Assistance; Nutritional
Monitoring; Spiritual Support
Reference
Lennie, T. A. (2006, MarchApril). Factors influencing food intake in patients
with heart failure: A comparison with healthy elders. The Journal of Car-
diovascular Nursing, 21(2), 123129.
RISK FOR FALLS

DEFINITION
Increasing susceptibility to falling that may cause physical harm
RISK FACTORS
Adult Patient verbalizes faintness
Age 65 years when extending neck
Lives alone Difficulties with hearing or
Environmental hazards (e.g., vision
cluttered environment; poor Incontinence
lighting) Child
Presence of lower limb pros- Age 2 years
thesis; use of assistive devices Environmental hazards (e.g.,
for walking bed located near window, lack
Has history of falls of gate on stairs)
Use of alcohol, diuretics, and Lack of parental supervision
tranquilizers Unattended infant on elevated
Presence of anemias, diarrhea surface (e.g., bed/changing table)
Cardiac function Sensation/perception
Knowledge
EXPECTED OUTCOMES
Patient and family will
Identify factors that increase potential for falling.
Assist in identifying and applying safety measures to prevent injury.
Make necessary changes in the physical environment to ensure
safety for the patient.
Develop long-term strategies to promote safety and prevent falls.
Optimize patients ability to carry out ADLs within sensor motor
limitations.
Ambulation; Balance; Cognition; Neurological Status; Risk Control;
Sensory Function: Vision; Sensory Function: Hearing
Determine: For adults, assess severity of sensory or motor deficits;
environmental hazards, and inadequate lighting; medication use;
improper use of assistive devices.
For children, assess sensory or motor deficits, recent illnesses,
unsteady balance, running at speeds beyond capability, and
inadequate supervision. Assessment factors will help identify appro-
priate interventions.
Perform: For older adults, make necessary changes in environment
(i.e., remove throw rugs). Orient patient to environment. Post a
127
notice that the patient is at risk for falling. Place side rails up and
bed position down when the patient is in bed. Place personal items
within the patients reach. These measures prevent injury to patient.
For children, make necessary changes in environment (i.e., apply
window guards); keep toys and other objects from lying around on
the floor; use a gate when necessary to keep the child in a confined
area; provide adequate supervision to prevent injury to the patient.
Inform: Provide family with a list of all the things they need to do
to prevent the patient from falling. Go over each item and explain
the reason for each cautionary measure. Written instructions will
reinforce the need for prevention.
Teach patient with an unstable gait how to use assistive devices
properly. Improper use of assistive devices can put the patient at
greater risk of falling.
Teach patient and family about the use of safe lighting. Advise
patients to wear sunglasses to reduce glare. Proper lighting is always
considered as a preventive measure.
Teach patient about medications that have been prescribed for
him or her. Overmedication in older adults is one of the major risk
factors in falls. Understanding on the part of the patient and family
can reduce the incidence of falls in the home.
Attend: Ask frequently during hospitalization whether patient and
family have questions about the modifications needed to prevent
falls. Listen carefully to statement or ideas the patient and/or family
may present about potential for falls in their individual home
settings. Greater awareness on the part of both patient and family
can markedly reduce the risk of falls.
Encourage adult patient to express feelings about the fear of falling.
Being able to express the fear will raise the nurses awareness of
what the patient considers problem areas.
Manage: Arrange for social service/case manager to make a home
visit to help prepare the family for the patients return to a safe
environment.
Refer patient and family to community resources that may offer
assistance to the patient when needed.
Environmental Management; Exercise Therapy: Balance; Fall Preven-
tion; Medication Management; Teaching
Reference
Bright, L. (2005, January). Strategies to improve the patient safety outcome
indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1), 2936.
DYSFUNCTIONAL FAMILY PROCESSES:

ALCOHOLISM
DEFINITION
Psychosocial, spiritual, and physiological functions of the family unit
are chronically disorganized, which leads to conflict, denial of prob-
lems, resistance to change, ineffective problem solving, and a series
of self-perpetuating crises
Alcohol abuse; agitation; blaming; broken promises
Deficient knowledge about alcoholism
Denial of problems; difficulty with intimate relationships
Enabling to maintain alcoholic drinking pattern
Rationalization; moodiness; rejection; tension
Triangulating family relationships
Marital problems; ineffective spousal communication
RELATED FACTORS
Abuse of alcohol Family history of alcoholism
Addictive personality Family history of resistance to
Biochemical influences treatment
Behavior Communication
Emotional Knowledge
Coping Self-perception
Values and beliefs
EXPECTED OUTCOMES
Family members will
Acknowledge there is a problem with alcoholism within the family.
Sign contracts stating they will not engage in abusive behavior.
Communicate their needs, using I statements.
Discuss problems in an open, safe environment.
Acknowledge their strengths and progress in resolving problems.
State plans to continue to seek counseling and attend appropriate
support group meetings.
Family Coping; Family Functioning; Family Normalization; Role
Performance; Substance Abuse Consequences
Determine: Assess drinking pattern; use of other substances; patterns
of withdrawal; ability of alcoholic member to function in
occupational and familial roles; ability of family members to func-
tion in their roles; family health history; affiliation with a religious
group and religious practices. Assessment factors will assist in identi-
fying appropriate interventions.
Perform: Create an environment in which family members feel free
to express themselves honestly about the present situation to
129
decrease their anxiety and help family members develop confidence
in their ability to resolve problems.
Inform alcoholic family member that he will have to acknowledge
his alcoholism before progress can be made in rebuilding family
relations to establish abstinence as a basis for treatment.
Inform: Teach family members to communicate their needs
assertively. Have them practice using I statements to express feel-
ings to help them get in touch with their feelings.
Inform patient and family about the symptoms and effects of addic-
tive behaviors on both the patient and the family to help them under-
stand the role they play in both the disease and the recovery process.
Do interactive planning and role-playing with the patient and
family to help them gain the skills needed to effect necessary
changes in communication patterns in the family. Role-playing helps
create a realistic view of the behaviors that reinforce behaviors in
themselves and the patient.
Attend: Encourage family members to acknowledge that alcoholism is
a problem within the family in order to break through family denial.
Ask alcoholic family member to sign a contract stating he will
abstain from alcohol to help him take responsibility for his own
behavior.
Help family members evaluate the consequences of abusive and vio-
lent behavior. Inform them that any suspected abuse will be reported.
Ask family members to sign contracts so they will not continue to
abuse one another to make them take responsibility for their behavior.
Being able to identify strengths provides the confidence the family
needs to continue working toward a positive outcome for both
patient and family.
Assist family members to identify their strengths and talk about
progress they have made in resolving problems associated with alco-
holism or living with a family member who has alcoholism.
Provide additional emotional support to the head of the family
about altered role and additional responsibility to build self-esteem.
Manage: Refer family for continued family therapy so they can con-
tinue the process of restructuring their lives.
Refer patient and family to AA, Alanon, or other appropriate sup-
port group to establish the importance of abstinence.
Coping Enhancement; Family Process Maintenance; Family Support;
Substance Use Prevention; Substance Use Prevention
Reference
Fowler, T. L. (2006, July). Alcohol dependence and depression: Advanced
nursing interventions. Journal of the American Academy of Nurse
Practitioners, 18(7), 303308.
INTERRUPTED FAMILY PROCESSES

DEFINITION
Change in family relationship or functioning
Changes in:
Assigned tasks
Availability for affective responses and/or emotional support
Communication patterns
Effectiveness in completing assigned tasks
Expressions of conflict within family and/or community resources
Expressions of isolation from community resources
Intimacy
Participation in problem solving and/or decision making
Stress-reduction behaviors
RELATED FACTORS
Developmental crises Modification in family finances
Developmental transition Modification in family social
Family role shift status
Interaction with community Situational transition
Communication Emotional
Coping Roles/relationship
EXPECTED OUTCOMES
Family members will
Not experience physical, verbal, emotional, or sexual abuse.
Communicate clearly, honestly, consistently, and directly.
Establish clearly defined roles and equitable responsibilities.
Express understanding of rules and expectations.
Report the methods of problem solving and resolving conflicts
have improved.
Report a decrease in the number and intensity of family crises.
Seek ongoing treatment.
Family Coping; Family Functioning; Family Normalization; Social
Interaction Skills; Substance Addiction Consequences
Determine: Assess familys developmental stage, roles, rules, socioeco-
nomic status, health history, history of substance abuse; history of sex-
ual abuse of spouse or children, problem-solving and decision-making
131
skills, and patterns of communication. Assessment information will
provide development of appropriate interventions.
Perform: Meet with family members to establish levels of authority
and responsibility in the family. Understanding the family dynamics
provides information about the kinds of support the family needs to
work with the patients issues.
Create an environment in which family members can express
themselves openly and honestly to build trust and self-esteem.
Establish rules for communication during meetings with the family
to assist family members to take responsibility for their own behavior.
Inform: Teach family members basic communication skills to enable
them to discuss issues in a positive way. Have them role-play with
one another numerous times to demonstrate what has been learned.
Involve the family in exercises to reduce stress and deal with
anger.
Attend: Hold adults accountable for their alcohol or substance abuse
and have them sign a Use contract to decrease denial, increase
trust, and promote positive change.
ity to participate will encourage greater compliance with the plan.
Assist family to set limits on abusive behaviors and have them
sign Abuse contracts to foster feelings of safety and trust.
assessment is done.
Refer to support groups that deal with substance abuse, domestic
violence, or sexual abuse depending on the needs of the patient
and/or family to enhance interpersonal skills and strengthen the fam-
ily unit.
Provide all appropriate phone numbers so that the family
members can initiate whatever follow-up is needed.
Coping Enhancement; Family Integrity Promotion; Family Process
Maintenance; Family Support; Normalization Promotion; Substance
Use Prevention; Substance Use Treatment
Reference
Yonaka, L., et al. (2007, JanuaryFebruary). Barriers to screening for domestic
violence in the emergency department. Journal of Continuing Education for
Nursing, 38(1), 3745.

FAMILY PROCESSES
DEFINITION
A pattern of family functioning that is sufficient to support the well-
being of family members and can be strengthened
Activities support the growth of family members
Activities support the safety of family members
Balance exists between autonomy and cohesiveness
Boundaries of family members are maintained
Energy level of family supports ADLs
Family adapts to change
Relationships are generally positive
Respect for family members is positive
Roles/relationship Coping
EXPECTED OUTCOMES
Family members will
Identify family goals and structured directions.
Express enjoyment and satisfaction with their roles in the family.
Express a willingness to enhance roles in family dynamics.
Participate regularly in traditional family activities.
Maintain open and positive communication.
Maintain a safe home environment.
Seek regular health screenings and immunizations.
Identify and acknowledge family risk factors.
Make plans to deal with life changes and events.
Family Coping; Family Functioning; Family Health Status; Family
Integrity; Family Normalization; Family Social Climate
Determine: Assess family composition, roles within the family,
communication patterns, family developmental stages, developmen-
tal tasks, health patterns, coping mechanisms, socioeconomics,
educational levels, ethnicity, and cultural and religious beliefs.
Assessment information helps identify appropriate interventions.
Perform: Establish an environment in which family members can
openly share their issues and concerns in comfort to reduce anxiety
and develop their ability to resolve problems.
Inform: Explain importance of setting goals as a method of estab-
lishing boundaries that will be respected by all family members.
Family functioning with structural direction will enhance the poten-
tial to meet physical, social, and psychological needs.
133
Show family how to develop a Genogram to identify genetic risk
factors. Information from the Genogram will highlight things that
can modify a familys health patterns, lead to early identification of
genetically related diseases, and may delay onset of disease.
Teach value of daily exercise, well-balanced diet, and use of
proven holistic strategies to improve health.
Provide family with information on recommended health screen-
ings and immunization schedules. It is essential to keep immuniza-
tions given according to schedule to prevent loss of immunity.
Attend: Encourage family members to identify individual and family
goals and a structured direction toward sound health habits for the
entire family. Developing a structured plan will assist in having
everyone work together toward goals set by the family for
themselves.
Involve family in planning and decision making. Having the abil-
ity to participate encourages greater compliance with the plan.
Encourage family to spend time together enjoying traditional
activities that everyone likes doing to promote a healthy lifestyle and
encourage strong family unity.
Manage: Refer, where requested, for follow-up for a family member
who needs exercise, weight management, diet assistance, health
screenings, and so forth. Providing referrals will help to provide
continuity of care for the patient.
Family Support; Family Integrity Promotion; Family Maintenance
Reference
Yanaka, L., et al. (2007, JanuaryFebruary). Barriers to screening for domestic
violence in the emergency departments. Journal of Continuing Education in
Nursing, 38(1), 3745.
FATIGUE
DEFINITION
An overwhelming sustained sense of exhaustion and decreased
capacity for physical and mental work at usual level
Decreased libido or performance
Disinterest in surroundings
Drowsiness
Failure of sleep to restore energy
Lack of energy
Guilt for not meeting responsibilities
Inability to maintain usual routines
Impaired concentration
Increased need for rest
Increased physical complaints
Lethargy or listlessness
Perceived need for more energy for routine tasks
Verbalization of overwhelming lack of energy
RELATED FACTORS
Psychological, e.g., anxiety, Environmental, e.g., humidity,
depression, stress lights, noise, temperature
Physiological, e.g., anemia, dis- Situational, e.g., negative life
ease states, malnutrition, preg- events, occupation
nancy, poor physical condition
Activity/exercise Reproduction
Cardiovascular function Respiratory function
Neurocognition Sleep/rest
Nutrition
EXPECTED OUTCOMES
The patient will
Identify and employ measures to prevent or modify fatigue.
Explain relationship of fatigue to disease process and activity level.
Verbally express increased energy.
Articulate plan to resolve fatigue problems.
Activity Tolerance; Endurance; Energy Conservation; Nutritional Sta-
tus: Energy; Psychomotor Energy; Personal Well-Being
Determine: Assess usual patterns of sleep and activity to establish a
baseline.
135
Perform: Conserve energy through rest, planning, and setting priori-
ties to prevent or alleviate fatigue. Alternate activities with periods
of rest. Avoid scheduling two energy-draining procedures on the
same day. Encourage activities that can be completed in short peri-
ods. These measures help to avoid overexertion and increase stamina.
Reduce demands placed on patient (e.g., ask one family member
to call at specified times and relay messages to friends and other
family members) to reduce physical and emotional stress.
Structure environment (e.g., set up daily schedule on the basis of
patient needs and desires) to encourage compliance with treatment
regimen.
Postpone eating when patient is fatigued, to avoid aggravating
condition. Provide small, frequent feedings to conserve patients
energy and encourage increased dietary intake.
Establish a regular sleeping pattern. Getting 810 hr of sleep
nightly helps reduce fatigue.
Inform: Discuss effect of fatigue on daily living and personal goals.
Explore with patient relationship between fatigue and disease
process to help increase patient compliance with schedule for activ-
ity and rest.
Attend: Encourage patient to eat foods rich in iron and minerals,
unless contraindicated to help avoid anemia and demineralization.
Manage: Encourage patient to explore feelings and emotions with a
supportive counselor, clergy, or other professional to help cope with
illness and avoid aggravating fatigue.
Activity Therapy; Coping Enhancement; Energy Management;
Exercise Promotion; Sleep Enhancement
Reference
Barsevick, A. M., et al. (2006, SeptemberOctober). Cancer-related fatigue,
depressive symptoms, and functional status: A mediation model. Nursing
Research, 55(5), 366372.
FEAR
DEFINITION
Response to a perceived threat that is consciously recognized as a
danger
Behaviors involving aggression, avoidance, impulsivness, increased
alertness, and narrowed focus of the source of fear
Cognitive effects such as decreased self-assurance, productivity, and
ability to problem solve
Feelings of alarm, apprehension, increased tension, panic, and terror
Physiological changes including increased heart rate, respiration
rate, perspiration, and/or blood pressure; anorexia, nausea, vomit-
ing, diarrhea, muscle tightness, fatigue, and shortness of breath
and pallor
RELATED FACTORS
Language barrier Separation from support
Learned response system
Phobic stimulus Unfamiliarity with
Sensory impairment environmental experience
Behavior Risk management
Coping Sleep/rest
Physical regulation
EXPECTED OUTCOMES
The patient will
Identify source of fear.
Communicate feelings about separation from support systems.
Communicate feelings of comfort or satisfaction.
Use situational supports to reduce fear.
Integrate into daily behavior at least one fear-reducing coping
mechanism, such as asking questions about treatment progress or
making decisions about care.
Anxiety Control; Comfort Level; Coping; Fear Control; Pain Level
Determine: Ask patient to identify source of fear; assess patients
understanding of situation. Perceptions may be erroneously based.
Perform: Help patient maintain daily contact with family: Arrange
for telephone calls; help write letters; promptly convey messages to
patient from family and vice versa; encourage patient to have
pictures of loved ones; provide privacy for visits; take patient to day
room or other quiet area. These measures help patient reestablish
and maintain social relationships.
137
Involve patient in planning care and setting goals to renew confi-
dence and give a sense of control in a crisis situation. If patient has
no visitors, spend an extra 15 min each shift in casual conversation;
encourage other staff members to stop for brief visits. These meas-
ures help patient cope with separation.
Administer antianxiety medications, as ordered, and monitor effec-
tiveness. Drug therapy may be needed to manage high anxiety levels
or panic disorders.
Inform: Instruct patient in relaxation techniques such as imagery and
progressive muscle relaxation to reduce symptoms of sympathetic
stimulation.
Answer questions and help patient understand care to reduce anx-
iety and correct misconceptions.
Attend: When feasible and where policies permit, relax visiting
restrictions to reduce patients sense of isolation.
Allow a close family member or friend to participate in care to
provide an additional source of support.
Support family and friends in their efforts to understand patients
fear and to respond accordingly to help them understand that
patients emotions are appropriate in context of situation.
Manage: Refer patient to community or professional mental health
resources to provide assistance.
Active Listening; Anxiety Reduction; Cognitive Restructuring; Coun-
seling; Coping Enhancement; Decision-Making Support; Security
Enhancement; Presence; Support Group
Reference
Cookman, C. (2005, June). Attachment in older adulthood: Concept clarifica-
tion. Journal of Advanced Nursing, 50(5), 528535.

FLUID BALANCE
DEFINITION
A pattern of equilibrium between fluid volume and chemical compo-
sition of body fluids that is sufficient for meeting physical needs and
can be strengthened
Verbalization of willingness to enhance fluid balance
Stable weight
Moist mucous membranes
Food and fluid intake adequate for daily needs
Straw-colored urine with specific gravity within normal limits
Good tissue turgor
No excessive thirst
Urine output appropriate for intake
No evidence of edema or dehydration
Activity/exercise Fluid and electrolytes
Elimination Respiratory function
EXPECTED OUTCOMES
The patient will
Have stable vital signs within normal ranges; electrocardiograph
shows no abnormality in rhythm.
Have normal skin temperature, moistness, turgor, and color.
Have moist and noncracked mucous membranes.
Have stable weight.
Have adequate fluid volume intake and thirst satiety.
Produce adequate urine volume (approximately equal to fluid
intake) of light to straw-colored urine.
Maintain a urine specific gravity between 1.015 and 1.025.
Have normal values for plasma and serum for electrolytes, osmo-
larity, glucose, blood urea nitrogen, hematocrit (HCT), and hemo-
globin (Hb).
Be alert and respond to demands of living; react appropriately to
reflex needs (i.e., thirst); have normal muscle reflexes, strength,
and tone.
Express understanding of factors that contribute to normal fluid
and electrolyte balance.
Adhere to prescribed therapies to manage such coexisting disease
processes.
Fluid Balance; Hydration; Nutritional Status: Food & Fluid Intake;
Tissue Integrity: Skin & Mucous Membranes; Vital Signs
139
Determine: Assess usual fluid intake and desire to improve fluid sta-
tus to establish a baseline.
Inform: Teach patient to read and interpret labels on beverage and
food containers. For example, humans require 0.5 g (500 mg) of
sodium per day; typical intake is 56 g daily. Reducing the amount
of sodium reduces the amount of fluid volume in the vascular
system.
Encourage adequate water intake (1,2002,000 ml) during
exercise or high environmental temperatures; unmeasured fluid losses
through diaphoresis and lung evaporation can be significant.
Teach signs and symptoms of dehydration (dry mouth and
mucous membranes), light-headedness (blood pressure and vital sign
changes), scant urine output (glycosuria and polyuria), and over-
hydration (cough, increased weight gain, dependent edema, and
jugular vein distention). Teaching prevents severe complications.
Attend: Encourage patient to select healthy beverages such as water
and limit beverages such as soda or sports drinks that have high
sugar content (which increase the osmolar content of the body, caus-
ing greater thirst and increased load on the renal system and diuresis)
and caffeine (which causes diuresis and may cause an increased fluid
loss), alcoholic beverages during hot weather because these can
cause fluid and electrolyte disturbances through excess diuresis.
Electrolyte Management; Fluid/Electrolyte Management; Fluid Man-
agement; Fluid Monitoring
Reference
Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is
needed in preventing, recognizing, and treating dehydration. American Journal
of Nursing, 106(6), 4049.
DEFICIENT FLUID VOLUME

DEFINITION
Decreased intravascular, interstitial, or intracellular fluid; water loss
alone without change in sodium
Changes in mental status
Decreased pulse volume and pressure, urine output, and venous
filling
Dry skin and mucous membranes
Increased body temperature, HCT, pulse rate, and urine concen-
tration
Low blood pressure
Poor turgor of skin or tongue
Sudden weight loss
Thirst
Weakness
RELATED FACTORS
Active fluid volume loss
Failure of regulatory mechanisms
Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain stable vital signs.
Have normal skin color.
Have electrolyte levels within normal range.
Maintain an adequate fluid volume.
Maintain an adequate urine volume.
Have normal skin turgor and moist mucous membranes.
Have a urine specific gravity between 1.005 and 1.010.
Have normal fluid and blood volume.
Express understanding of factors that caused fluid volume deficit.
Electrolyte & AcidBase Balance; Fluid Balance; Hydration; Nutri-
tional Status: Food & Fluid Intake
Determine: Monitor and record vital signs every 2 hr or as often as
necessary until stable. Then monitor and record vital signs every
4 hr. Tachycardia, dyspnea, or hypotension may indicate fluid
volume deficit or electrolyte imbalance.
Measure intake and output every 14 hr. Record and report sig-
nificant changes. Include urine, stools, vomitus, wound drainage,
141
nasogastric drainage, chest tube drainage, and any other output.
Low urine output and high specific gravity indicate hypovolemia.
Weigh patient daily at same time to give more accurate and con-
sistent data. Weight is a good indicator of fluid status.
Assess skin turgor and oral mucous membranes every 8 hr to
check for dehydration. Give meticulous mouth care every 4 hr to
avoid dehydrating mucous membranes.
Test urine specific gravity every 8 hr. Elevated specific gravity may
indicate dehydration.
Measure abdominal girth every shift to monitor for ascites and
third-space shift. Report changes.
Perform: Cover patient lightly. Avoid overheating to prevent vasodi-
lation, blood pooling in extremities, and reduced circulating blood
volume.
Administer fluids, blood or blood products, or plasma expanders
to replace fluids and whole blood loss and facilitate fluid movement
into intravascular space. Monitor and record effectiveness and any
adverse effects.
Dont allow patient to sit or stand up quickly as long as circula-
tion is compromised to avoid orthostatic hypotension and possible
syncope.
Administer and monitor medications to prevent further fluid loss.
Inform: Explain reasons for fluid loss, and teach patient how to
monitor fluid volume; for example, by recording daily weight and
measuring intake and output. This encourages patient involvement
in personal care.
AcidBase Management; Electrolyte Monitoring; Fluid Management;
Hypovolemia Management
Reference
Kelley, D. M. (2005, JanuaryMarch). Hypovolemic shock: An overview. Crit-
ical Care Nursing Quarterly, 28(1), 219.
EXCESS FLUID VOLUME

DEFINITION
Increased isotonic fluid retention
Altered mental status or respiratory pattern
Anasarca
Azotemia
Changes in blood pressure, pulmonary artery pressure, urine
specific gravity, and electrolyte levels
Crackles
Decreased Hb and HCT levels
Dyspnea
Edema
Increased central venous pressure (CVP)
Intake greater than output
Jugular vein distention
Oliguria
Orthopnea
Pleural effusion
Positive hepatojugular reflex
Pulmonary congestion
Rapid weight gain
Restlessness and anxiety
S3 heart sound
RELATED FACTORS
Compromised regulatory mechanism
Excess fluid intake
Excess sodium intake
Elimination Nutrition
Fluid and electrolytes Respiratory function
EXPECTED OUTCOMES
The patient will
State ability to breathe comfortably.
Maintain fluid intake at ___ ml/day.
Return to baseline weight.
Maintain vital signs within normal limits (specify).
Exhibit urine specific gravity of 1.0051.010.
Have normal skin turgor.
Show electrolyte level within normal range (specify).
Avoid complications of excess fluid.
143
Electrolyte Balance; Fluid Balance; Fluid Overload Severity; Kidney
Function; Nutritional Status: Food & Fluid Intake
Determine: Monitor and record vital signs at least every 4 hr.
Changes may indicate fluid or electrolyte imbalances. Measure and
record intake and output. Intake greater than output may indicate
fluid retention and possible overload.
Weigh patient at same time each day to obtain consistent
readings. Test urine specific gravity every 8 hr and record results.
Monitor laboratory values and report significant changes to
physician. High specific gravity indicates fluid retention. Fluid over-
load may alter electrolyte levels.
Assess patient daily for edema, including ascites and dependent or
sacral edema. Fluid overload or decreased osmotic pressure may
result in edema, especially in dependent areas.
Perform: Help patient into a position that aids breathing, such as
Fowlers or semi-Fowlers, to increase chest expansion and improve
ventilation.
Administer oxygen, as ordered, to enhance arterial blood oxygena-
tion. Restrict fluids to ____ ml per shift. Excessive fluids will worsen
patients condition.
Administer diuretics to promote fluid excretion. Record effects.
Maintain patient on sodium-restricted diet, as ordered, to reduce
excess fluid and prevent reaccumulation.
Reposition patient every 2 hr, inspect skin for redness with each
turn, and institute measures as needed to prevent skin breakdown.
Apply antiembolism stockings or intermittent pneumatic compres-
sion stockings to increase venous return. Remove for 1 hr every
8 hr or according to facility policy.
Inform: Educate patient regarding maintenance of daily weight
record, daily measuring and recording of intake and output, diuretic
therapy, and dietary restrictions, especially sodium. These measures
encourage patient and caregivers to participate more fully.
Attend: Encourage patient to cough and deep breathe every 24 hr
to prevent pulmonary complications.
Electrolyte Management; Fluid Management; Fluid Monitoring;
Nutrition Management
Reference
Bennett, S. J., et al. (2005, December). Medication and dietary compliance
beliefs in heart failure. Western Journal of Nursing Research, 27(8),
977993.
RISK FOR DEFICIENT FLUID VOLUME

DEFINITION
At risk for experiencing vascular, cellular, or intracellular
dehydration
RISK FACTORS
Conditions that influence fluid Knowledge deficit related to
needs (e.g., hypermetabolic state) fluid volume
Excessive loss of fluid from Loss of fluid through abnor-
normal routes (e.g., diarrhea) mal routes (e.g., drainage
Extremes of age or weight tube)
Factors that affect intake or Medications that cause fluid
absorption of, or access to, loss
fluids (e.g., immobility)
Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain stable vital signs.
Have normal skin color.
Maintain urine output of at least ___ ml/hr.
Maintain electrolyte values within normal range.
Maintain intake at _____ ml/24 hr.
Have an intake equal to or exceeding output.
Express understanding of need to maintain adequate fluid intake.
Demonstrate skill in weighing himself or herself accurately and
recording weight.
Measure and record own intake and output.
Return to normal, appropriate diet.
Electrolyte & AcidBase Balance; Fluid Balance; Hydration;
Nutritional Status: Food & Fluid Intake; Risk Detection; Urinary
Elimination
Determine: Monitor and record vital signs every 4 hr. Fever, tachy-
cardia, dyspnea, or hypotension may indicate hypovolemia.
Determine patients fluid preferences to enhance intake.
Maintain accurate record of intake and output to aid estimation
of patients fluid balance. Measure urine output every hour. Record
and report output of less than ____ ml/hr. Decreased urine output
may indicate reduced fluid volume. Measure and record drainage
from all tubes and catheters to take such losses into account when
replacing fluid.
145
When copious drainage appears on dressings, weigh dressings
every 8 hr and record with other output sources. Excessive wound
drainage causes significant fluid imbalances (1 kg dressing equals
about 1 qt [1 L] of fluid).
Test urine specific gravity each shift. Monitor laboratory values
and report abnormal findings to physician. Increased urine specific
gravity may indicate dehydration. Elevated HCT and Hb levels also
indicate dehydration.
Monitor serum electrolyte levels and report abnormalities. Fluid
loss may cause significant electrolyte imbalance.
Obtain and record patients weight at same time every day to help
ensure accurate data. Daily weighing helps estimate body fluid status.
Monitor skin turgor each shift to check for dehydration; report
any decrease in turgor. Poor skin turgor is a sign of dehydration.
Examine oral mucous membranes each shift. Dry mucous
membranes are a sign of dehydration.
Perform: Cover wounds to minimize fluid loss and prevent skin
excoriation.
Keep oral fluids at bedside within patients reach and encourage
patient to drink. This gives patient some control over fluid intake
and supplements parenteral fluid intake.
Force oral fluids when possible and indicated to enhance replace-
ment of lost fluids. (Bowel sounds should be present and patient
awake before giving oral fluids.)
Administer parenteral fluids, as prescribed, to replace fluid losses.
Maintain parenteral fluids or blood transfusions at prescribed rate to
prevent further fluid loss or overload.
Progress patient to appropriate diet, as prescribed, to help achieve
fluid and electrolyte balance.
Inform: Instruct patient in maintaining appropriate fluid intake,
including recording daily weight, measuring intake and output, and
recognizing signs of dehydration. This encourages patient and care-
giver participation and enhances patients sense of control.
AcidBase Management; Fluid Management; Fluid Monitoring;
Hypovolemia Management; Hypovolemia Intravenous Therapy;
Hypovolemia Monitoring; Surveillance
Reference
Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is
needed in preventing, recognizing, and treating dehydration. American Jour-
nal of Nursing, 106(6), 4049.
RISK FOR IMBALANCED FLUID VOLUME

DEFINITION
At risk for a decrease, increase, or rapid shift from one to the other
of intravascular, interstitial, and/or intracellular fluid. This refers to
body fluid loss, gain, or both
RISK FACTORS
Receiving apheresis Intestinal obstruction
Abdominal surgery Sepsis
Traumatic injury Pancreatitis
Burns Ascites
Cardiac function
Physical regulation
EXPECTED OUTCOMES
The patient will
Remain hemodynamically stable.
Not experience electrolyte imbalance.
Maintain adequate urine output.
Identify risk factors contributing to possible imbalanced fluid volume.
Fluid Balance; Hydration; Vital Signs
Determine: Assess for conditions that may contribute to imbalanced
fluid volume. Prompt treatment of the underlying cause may prevent
serious complications of fluid imbalance.
Monitor vital signs and other assessment parameters frequently.
Changes in heart rate and rhythm, blood pressure, and breath
sounds may indicate altered fluid status.
Monitor intake and output to evaluate need for fluid replacement.
Perform: Collect and evaluate urine output frequently. Measure urine
specific gravity as indicated. Decreased urine volume and elevated
specific gravity indicate hypovolemia.
Collect and evaluate serum electrolyte levels. Fluid alterations may
affect electrolyte levels.
Administer intravenous fluids as indicated. Proactive fluid manage-
ment may prevent serious imbalances.
Inform: Educate patient and family regarding fluid restrictions or
need for increased fluids, depending on underlying condition. Knowl-
edge will enhance feeling of participation and sense of control.
Attend: Provide encouragement and support for cooperation with
prescribed treatment regimen. Positive reinforcement will promote
compliance.
147
Manage: Coordinate care with other members of healthcare team to
effectively manage underlying medical condition and prevent any
alteration in fluid balance.
Fluid Management; Fluid Monitoring; Intravenous Therapy
Reference
Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled
water. Journal of Perianesthesia Nursing, 23, 267272.
IMPAIRED GAS EXCHANGE

DEFINITION
Excess or deficit in oxygenation and/or carbon dioxide elimination
at the alveolar-capillary membrane
Abnormal pH and arterial Headache upon awakening
blood gases levels Hypoxia and hypoxemia
Abnormal respiratory rate, Increased or decreased carbon
rhythm, and depth dioxide levels
Confusion Irritability/Restlessness
Cyanosis Nasal flaring
Diaphoresis Pale, dusky skin
Dyspnea Tachycardia
RELATED FACTORS
Alveolar-capillary membrane changes
Ventilationperfusion changes
EXPECTED OUTCOMES
The patient will
Carry out ADLs without weakness or fatigue.
Maintain normal Hb and HCT levels.
Express feelings of comfort in maintaining air exchange.
Cough effectively and expectorate sputum.
Be free from adventitious breath sounds.
Perform relaxation techniques every 4 hr.
Use correct bronchial hygiene.
Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital
Signs
Determine: Monitor respiratory status; rate and depth of breaths;
chest expansion; accessory muscle use; cough and amount and color
of sputum; and auscultation of breath sounds every 4 hr to detect
early signs of respiratory failure.
Monitor vital signs, arterial blood gases, and Hb levels to detect
changes in gas exchange.
Report signs of fluid overload or dehydration immediately. This
can lead to changes in acid-base balance and affect respiratory status.
Perform: Elevate head 30 to facilitate lung expansion and prevent
atalectasis. Assist with ADLs as needed to decrease tissue oxygen.
149
Perform bronchial hygiene as ordered (e.g., coughing, percussing,
postural drainage, and suctioning) to promote drainage and keep
airways clear. Administer bronchodilators, antibiotics, and steroids,
as ordered.
Record intake and output every 8 hr to monitor fluid balance.
Auscultate lungs every 4 hr and report abnormalities to detect
decreased or adventitious breath sounds.
Orient patient to the environment, that is, use of call bell, side
rails, and bed positioning controls. Place side rails up and bed
position down when the patient is in bed. Place personal items
within the patients reach. Assist patient when he or she is getting
out of bed in case of dizziness. These measures prevent risk of
falling. Move patient slowly to avoid hypostatic hypotension. Post
a notice where it can be seen that the patient is at risk for falling.
Inform: Teach and demonstrate correct breathing and coughing tech-
niques such as diaphragmatic or abdominal breathing and have
patient return demonstration to ensure patient understands proper
technique and promote effective coughing and deep breathing.
Teach patient correct way of using inhalers. Remind patient about
mouth care after each dose. Failure to clean the mouth after inhal-
ing can cause candidiasis in the throat.
Review all medications with patient and family and list side
effects for each to ensure that the patient recognizes side effects and
reports them to the physician.
Encourage relaxation techniques to reduce oxygen demand.
Attend: Encourage patient to express feelings. Attentive listening
helps build a trusting relationship.
Encourage family members to stay with the patient, especially
during times of anxiety to promote relaxation which reduces oxygen
demand.
Manage: Request for a case manager to make a home visit to help
prepare family for the patients return to a safe environment.
Refer patient to community resources and offer written informa-
tion that can be referred to when needed.
AcidBase Management; Airway Management; Airway suctioning;
Anxiety Reduction; Energy Management; Exercise Promotion; Fluid
Management
Reference
Marklew, A. (2006, JanuaryFebruary). Body positioning and its effect on
oxygenationA literature review. Nursing in Critical Care, 11(1), 1622.
DYSFUNCTIONAL GASTROINTESTINAL
MOTILITY
DEFINITION
Increased, decreased, ineffective, or lack of peristaltic activity within
the gastrointestinal system
Nausea Abdominal pain
Vomiting Absence of flatus
Abdominal distension Hard, dry stool
Change in bowel sounds Difficulty passing stool
(e.g., absent, hypoactive, Diarrhea
hyperactive) Abdominal cramping
Increased gastric residual Accelerated gastric emptying
RELATED FACTORS
Anxiety Malnutrition
Surgery Food intolerance (e.g., lactose,
Immobility gluten)
Pharmacological agents (e.g., Ingestion of contaminants
narcotics, laxatives, antibiotics, (e.g., food, water)
anesthesia) Enteral feedings
Aging Inactive lifestyle
Elimination
Physical regulation
EXPECTED OUTCOMES
The patient will
Verbalize strategies to promote healthy bowel function.
Acknowledge the importance of seeking medical help for persistent
alteration in GI motility.
Not experience any fluid and electrolyte imbalance as a result of
altered motility.
Understand the need for early ambulation following abdominal
surgery.
Bowel Elimination, Electrolyte and AcidBase Balance, Gastrointesti-
nal Function
Determine: Assess abdomen including auscultation in all four quad-
rants noting character and frequency to determine increased or
decreased motility.
Assess current manifestations of altered GI motility to help iden-
tify the cause of the alteration and guide development of nursing
interventions.
151
Monitor intake and output to identify need for restoration of fluid
balance.
Perform: Collect and evaluate laboratory electrolyte specimens. Some
altered motility states may require electrolyte replacement therapy.
Insert nasogastric tube as prescribed for patients with absent
bowel sounds to relieve the pressures caused by accumulation of air
and fluid.
Inform: Educate patients regarding importance of maintaining diet
high in natural fiber and adequate fluid intake. Fiber increases stool
bulk and softens the stool. Fluid will promote normal bowel elimi-
nation pattern.
Attend: Encourage activities such as walking as tolerated for patients
with decreased GI motility. Increased activity will stimulate peristal-
sis and facilitate elimination.
Manage: Coordinate with dietitian and other healthcare professionals
as needed to meet the unique needs of each individual patient.
Fluid/Electrolyte Management; Gastrointestinal Intubation; Tube
Care: Gastrointestinal
Reference
Sabol, V. K., & Carlson, K. K. (2007). Diarrhea: Applying research to bedside
practice. AACN Advanced Critical Care, 18, 3244.
RISK FOR DYSFUNCTIONAL

GASTROINTESTINAL MOTILITY
DEFINITION
Risk for increased, decreased, ineffective, or lack of peristaltic activity
within the gastrointestinal system
RISK FACTORS
Abdominal surgery Gastroesophageal reflux
Diabetes disease (GERD)
Prematurity Unsanitary food preparation
Decreased gastrointestinal Anxiety
circulation Lifestyle
Pharmaceutical agents (e.g., Immobility
narcotics, antibiotics, proton Food intolerance (e.g., gluten,
pump inhibitors, and laxatives) lactose)
Nutrition Fluid and electrolytes
Elimination Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain adequate fluid and electrolyte balance.
Identify diet selections and lifestyle changes that would promote
healthy GI function.
Not experience altered GI motility related to prescribed
medications.
Recognize chronic conditions that may contribute to altered GI
motility, for example, diabetes, GERD.
Electrolyte and AcidBase Balance; Fluid Balance; Bowel Elimination
Determine: Assess patient for signs of fluid or electrolyte imbalance
related to increased or decreased GI motility. Fluid and electrolyte
alterations can result from either increased or decreased
gastrointestinal motility.
Assess patient for positive risk factors for altered GI motility. This
will allow for timely interventions to prevent complications associ-
ated with GI dysfunction.
Perform: Assist patients taking prescribed medications that affect
motility with strategies to avoid GI complications. Awareness of pre-
ventive measures will decrease GI complications.
Encourage early ambulation for postoperative patients receiving
opioids for pain control. Early ambulation will reduce the risk of
narcotic-related constipation.
Inform: Educate patient regarding the risk factors related to altered
GI motility, including certain food choices, fluid intake, medications,
153
and activity. Promotion of healthy lifestyle choices will contribute to
positive patient outcomes.
Attend: Provide encouragement and support for behaviors that
enhance gastrointestinal health. Positive reinforcement results in
improved confidence in self-management of health behaviors.
Manage: Coordinate care with other disciplines as needed to
reinforce positive behaviors or to assist with complex situations.
Diarrhea Management; Electrolyte Monitoring; Fluid Management;
Nutrition Management
Reference
Mazumdar, A., Mishra, S., Bhatnagar, S., & Gupta, D. (2008). Intravenous
morphine can avoid distressing constipation associated with oral morphine:
A retrospective analysis of our experience in 11 patients in the palliative
care in-patient unit. The American Journal of Hospice & Palliative Care,
25, 282284.
RISK FOR UNSTABLE BLOOD GLUCOSE

DEFINITION
At risk for variation of blood glucose/sugar levels from the normal
range
RISK FACTORS
Deficient knowledge of Lack of adherence to diabetes
diabetes management management
Developmental level Physical activity level
Dietary intake Physical/mental health status
Inadequate blood glucose Pregnancy
monitoring Stress
Lack of acceptance of diagnosis Weight gain or loss
Emotional Nutrition
Physical regulation Tissue integrity
EXPECTED OUTCOMES
The patient will
Be free from symptoms of hypoglycemia/hyperglycemia.
Have serum glucose to the prescribed desired range.
Verbalize understanding of how to control blood glucose level.
Blood Glucose Level; Diabetes Self-Management; Knowledge:
Diabetes Management, Weight Control
Determine: Assess patient for symptoms of low serum glucose level
and maintain a patient airway if indicated. A low serum glucose
may not be detected in some patients until moderate to severe cen-
tral nervous system impairment occurs, which can lead to a compro-
mised airway and cardiac arrest.
Assess for the underlying cause (e.g., inadequate dietary intake;
illness such as nausea, vomiting, or diarrhea; and too much insulin)
to help patient prevent future episodes and adapt treatment strate-
gies and lifestyle changes.
Monitor or instruct patient to monitor glucose levels with a glu-
cometer at regular intervals to identify and respond early to fluctua-
tions in glucose levels that occur outside normal parameters.
Assess family understanding of prescribed treatment regimen. The
family plays an important role in supporting the patient.
Assess patients knowledge of hypo/hyperglycemia to ensure ade-
quate management and prevent future episodes.
Monitor for signs and symptoms of hyperglycemia (polyuria, poly-
dipsia, polyphagia, lethargy, malaise, blurred vision, and headache).
Early detection ensures prompt intervention and management.
155
Assess for the underlying cause of elevated serum glucose level,
including inadequate dietary intake, illness, and poor medication
management to prevent future episodes and develope treatment
strategies such as changes in lifestyle.
Perform: Perform immediate finger stick with a glucometer to deter-
mine glucose level, which will guide treatment strategies. Administer
insulin, as prescribed, to treat elevated blood glucose levels.
Provide patient with glucose tablets or gel if he or she is
conscious and has ability to swallow. Administer intravenous glucose
if patient is unconscious or cannot swallow. Immediate treatment in
the form of oral or intravenous glucose must be administered to
reverse the low serum glucose level. If patient becomes nauseated,
turn patient on side to prevent aspiration.
Protect patient from injuries, such as falls. Symptoms of low
serum glucose place patient at risk for injury especially when driving
and performing other potentially dangerous activities.
Evaluate serum electrolyte levels. Administer potassium, as
prescribed. With elevated blood glucose levels, potassium and
sodium levels may be low, normal, or high, depending on the
amount of water loss. Consider performing serum testing for
HgbA1c (glycosylated hemoglobin A3C level) to evaluate average
blood glucose levels over a period of approximately 23 months and
to assess the adherence and effectiveness of the treatment regimen.
Inform: Teach patient and family self-management of hypoglycemia
and hyperglycemia including glucose monitoring at regular intervals
to treat abnormal glucose levels early and medication management,
nutritional intake, exercise, and regular follow-up visits with the
physician to ensure adequate understanding and management of the
treatment regimen to prevent future hyperglycemic events. Patient
and family teaching may include referrals to a diabetic educator, dia-
betic education classes, and a dietician.
Manage: Consult physician if signs and symptoms persist. Changes
in prescribed medications may be needed, such as with oral
hypoglycemic agents or insulin dosing. Call for emergency medical
services if patient is unstable outside the hospital.
Bedside Laboratory Testing; Health Education; Health Screening;
Nutritional Counseling; Teaching: Disease Process; Teaching:
Prescribed Medications
Reference
Oldroyd, J., et al. (2006). Randomized controlled trial evaluating lifestyle
interventions in people with impaired glucose tolerance. Diabetes Research
and Clinical Practice, 72(2), 117127.
GRIEVING
DEFINITION
A normal complex process that includes emotional, physical, spiri-
tual, social, and intellectual responses and behaviors by which indi-
viduals, families, and communities incorporate an actual,
anticipated, or perceived loss into their daily lives
Altered communication patterns
Change in eating, sleep and dream patterns, activity level, or libido
Denial of potential loss of life
Difficulty taking on different roles
Expressed guilt, anger, sorrow, and bargaining
Expressions of distress over potential loss of life
RELATED FACTORS
Anticipatory loss of significant object or other
Death of a significant other
Loss of significant object (e.g., possession, job, status)
Growth and Development Roles/relationships
Risk management Behavior
Emotional Communication
Values/beliefs
EXPECTED OUTCOMES
The patient will
Express and accept feelings about anticipated death.
Progress through stages of grieving process in his or her own way.
Practice religious rituals and use other coping mechanisms appro-
priate to end of life.
Have participation of family members or significant other in pro-
viding supportive care and comfort to patient.
Coping; Family Coping; Grief Resolution; Psychosocial Adjustment:
Life Change
Determine: Assess stage of grieving to establish a baseline.
Perform: Demonstrate acceptance of patients response to his or her
anticipated death, whatever that response may be: crying, sadness,
anger, fear, or denial. Each patient responds to dying in his or her
own way. Helping patient express feelings freely will enhance ability
to cope.
Help patient progress through psychological stages associated with
anticipated death, including shock and denial, anger, bargaining,
depression, and acceptance, to help you anticipate the dying
157
patients psychological needs. Keep in mind, however, that not all
dying patients go through each stage.
Provide time for patient to express his or her feelings about death
or terminal illness. Active listening helps the patient lessen feelings
of loneliness and isolation. Refrain from approaching patient with a
busy, hurried attitude, which can block communication.
Establish a relationship that encourages patient to express
concerns about death. Basic nursing care combined with genuine
interest in the patient fosters trust and understanding.
Guide patient in life review. Encourage patient to write or tape-
record his or her life history as a lasting gift to family members.
Life review allows patient to survey events from his or her past and
give them meaningful interpretation.
Inform: Inform patient about hospice services that emphasize symp-
tomatic relief and caring, with the aim of improving patient and
family comfort until death occurs, instead of prolonging life for its
own sake. Hospice care is an appropriate alternative for a patient
with an incurable illness.
Attend: Encourage family members to become involved in the care
of the dying patient. Communicate with patient and family members
honestly and compassionately. Giving family members a role in
patient care helps relieve anxiety and lessen feelings of regret and
guilt. Honest communication is important because family members
need an opportunity to acknowledge their loss and say farewell.
Support patients spiritual coping behaviors. For example, arrange
for patient to have objects that provide spiritual comfort (such as a
copy of Bible, prayer shawl, pictures, statues, or rosary beads) at the
bedside. Even patients for whom religious practice hasnt been a
dominant part of life may turn to religion when confronted by
death or serious illness.
Manage: Involve an interdisciplinary team (including a psychologist,
nurse, the patient, a nutritionist, physician, physical therapist, and
chaplain) in providing care for a dying patient. Each team member
offers unique expertise for meeting the dying patients needs.
Provide referrals for home healthcare assistance if the patient will be
cared for at home to support the patients decision to remain at home.
Anticipatory Guidance; Coping Enhancement; Family Support; Grief
Work Facilitation
Reference
Zimmerman, C., & Wennberg, R. (2006, AugustSeptember). Integrating pal-
liative care: A postmodern perspective. The American Journal of Hospice
and Palliative Care, 23(4), 255258.
COMPLICATED GRIEVING
DEFINITION
A disorder that occurs after the death of a significant other, in which
the experience of distress accompanying bereavement fails to follow
normative expectations and manifests in functional impairment
Decreased functioning in life roles
Decreased sense of well-being
Depression
Fatigue
Grief avoidance
Longing for the deceased
Low levels of intimacy
Persistent emotional distress
Preoccupation with thoughts of the deceased
Rumination
Searching for the deceased
Verbalization of anxiety; distress about the deceased; detachment
from others; self-blame; disbelief, mistrust, failure to accept the
death; feeling dazed, empty, in shock, or stunned; persistent
painful memories
RELATED FACTORS
Death of a significant other Lack of social support
Emotional instability Sudden death of significant other
Coping Emotional
Sleep/rest Values/beliefs
Nutrition Roles/relationships
EXPECTED OUTCOMES
The patient will
Express appropriate feelings of loss, guilt, fear, anger, or sadness.
Identify the loss and describe what it means to him.
Appropriately move through stages of grief.
Maintain healthy patterns of sleep, activity, and eating.
Verbalize understanding that grief is normal.
Use healthy coping mechanisms and social support systems.
Seek fulfillment through preferred spiritual practices.
Begin planning for future.
Grief Resolution; Life Change; Psychosocial Adjustment
Determine: Identify previous losses and assess for depression. Older
patients may experience losses frequently and without adequate
159
recovery time before the next loss. Multiple losses contribute to
depression.
Perform: Help patient identify an area of hope in his or her life.
Focusing on a life purpose may decrease anger and feelings of frus-
tration.
Help patient focus realistically on changes the loss has brought
about. This will assist patient in forming plans for the future and
improving social relationships.
Help patient formulate goals for the future to place loss in
perspective and move on to new situations and relationships.
Attend: Encourage patient to express grief and feelings of anger,
guilt, and sadness. Inability to express these feelings may result in
maladaptive behaviors.
Encourage journaling to express grief and loss. Writing and
exploring feelings is an active process, which may assist in grieving.
Encourage patient and family to engage in reminiscing to give
purpose and meaning to the loss and assist in maintenance of self-
esteem.
Manage: Contact patients preferred spiritual leader, if patient
desires, to provide relief from spiritual distress.
Refer patient to community support systems to help him deal with
his bereavement and grief process.
Coping Enhancement; Counseling; Emotional Support; Family Ther-
apy; Grief Facilitation Work
Reference
Szanto, K., et al. (2006, February). Indirect self-destructive behavior and overt
suicidality in patients with complicated grief. Journal of Clinical Psychiatry,
67(2), 233239.
RISK FOR COMPLICATED GRIEVING

DEFINITION
At risk for a disorder that occurs after the death of a significant other,
in which the experience of distress accompanying bereavement fails to
follow normative expectations and manifests in functional impairment
RISK FACTORS
Death of a significant other
Emotional instability
Lack of social support
Coping Roles/relationships
Emotional status Sleep/rest
Nutrition status Values/beliefs
EXPECTED OUTCOMES
The patient will
Express appropriate feelings of loss, guilt, fear, anger, or sadness.
Identify loss and describe meaning of loss.
Appropriately move through stages of grieving.
Maintain healthy patterns of sleep, activity, and eating.
List personal strengths.
Use healthy coping mechanisms and social support systems.
Seek fulfillment through preferred spiritual practices.
Begin planning for future.
Grief Resolution; Life Change Adjustment
Determine: Identify areas of hope in patients life to help decrease
anger and feelings of frustration.
Identify previous losses and assess for depression to establish a
baseline.
Perform: Perform interventions to promote sleep such as giving
snack, pillows, backrub, or shower to enhance rest.
Inform: Teach patient relaxation techniques such as guided imagery,
meditation, or progressive muscle relaxation to promote feelings of
comfort.
Attend: Encourage patient to express grief and feelings of anger,
guilt, and sadness. Inability to express these feelings may result in
maladaptive behaviors.
Encourage patient to express feelings in a way he is most comfort-
able with, for example, crying, talking, writing, and/or drawing.
Dysfunctional grieving may result from an inability to express
feelings freely.
161
Encourage patient to keep a journal to express feelings of grief
and loss. The act of writing about feelings may aid in grieving
process. Help patient form goals for the future to place the loss in
perspective and to move on to new situations and relationships.
Manage: Refer patient to community support systems to assist with
grieving process. Contact patients preferred spiritual leader if
patient desires. This may provide relief from spiritual distress.
Coping Enhancement; Counseling; Emotional Support; Family Ther-
apy; Grief Facilitation Work
Reference
Pilkington, F. B. (2008, January). Expanding nursing perspectives on loss and
grieving. Nursing Science Quarterly, 21(1), 67.
DELAYED GROWTH AND DEVELOPMENT

DEFINITION
Deviations from age-group norms
Altered physical growth
Delay or difficulty in performing motor, social, or expressive skills
typical of age group
Flat affect
Listlessness and decreased response
Inability to perform self-care activities or maintain self-control at
age-appropriate level
RELATED FACTORS
Effect of physical disability Multiple caretakers
Environmental deficiencies Prescribed dependence
Inadequate caretaking Separation from significant
Inconsistent responsiveness others
Indifference Stimulation deficiencies
Activity Family roles and responsibilities
Cardiac function Nutrition
Communication Sleep
EXPECTED OUTCOMES
The child will
Demonstrate skills appropriate for age.
Participate in developmental stimulation program to increase skill
levels.
The parents will
Express understanding of norms for growth and development.
Use community resources to promote childs development.
Provide play activities to promote childs development.
Child Development: Middle Childhood; Growth; Physical
Maturation: Female; Physical Maturation: Male
Determine: Monitor weight and height weekly. Monitor nutritional
intake, activity level, and sleep patterns. Documentation of these
factors will help measure progress over time.
Assess cardiac functioning and respiratory status to ensure that
child is healthy enough to participate in activities.
Assess childs motor skills, communication patterns, social skills, and
cognitive abilities to evaluate where skill development may be needed.
Assess support systems available to child and parents. Where there
are gaps, other sources of support may need to be put in place.
163
Perform: Establish a meal program to promote nutritional needs.
Weigh and measure child weekly and review growth-chart curve to
monitor progress.
Establish a routine sleep schedule for child to ensure that the
child is healthy enough to participate in an activity.
List age-appropriate activities and exercises to stimulate bone and
muscle development and promote cardiovascular health. Provide
appropriate play activities, such as building blocks, dolls, crayons,
or games to promote development.
Administer prescribed drugs and treatments as ordered. Ensure
parents and child understand intended action and possible side effects
to ensure therapy will continue as planned.
Provide an environment that is conducive to promote changes the
child must make. Environment can be a powerful motivator.
Inform: Provide parents with information about the causes of
delayed growth and development. Provide written information to
help them know what they can expect as a result of treatment.
Discuss age appropriate nutritional requirements with parents and
child and teach additional risk factors associated with delayed
growth (e.g., lack of regular sleep, environmental hazards). Teach
appropriate activities and encourage frequent play with child. These
measures promote continuity of care.
Attend: Five child positive reinforcement for demonstrating appropri-
ate skills and behavior and encourage parents to do the same to
encourage the child to continue developing skills.
Encourage child and parents to express feelings about present
state of childs health. Listen attentively with understanding about
the self-esteem associated with what is considered by peers to be
other than normal. Parents need to be encouraged first to accept the
child as he is and then encourage the child to develop new skills
Development can occur only when parents and staff are both realis-
tic about the child's present stage of development.
Manage: Provide parents with referrals to appropriate community
resources, including sources for financial assistance, child care, and
suppliers of adaptive equipment, to ensure the childs right to receive
remedial and educational support in accordance with the disability,
as guaranteed by federal law.
Developmental Enhancement: Child; Health Screening; Nutrition
Management; Risk Identification; Self-Responsibility Facilitation
Reference
Wagner, J., et al. (2006, SeptemberOctober). Nurses utilization of parent
questionnaires for developmental screening. Pediatric Nursing, 32(5),
409412.
RISK FOR DISPROPORTIONATE GROWTH

DEFINITION
At risk for growth above the 97th percentile or below the 3rd per-
centile for age, crossing the percentile channels
RISK FACTORS
Altered nutritional status Inability to digest and absorb
Any disease that persists over nutrients
time, especially during critical Neuroendocrine factors, such
periods of development as altered levels of growth or
Environmental hazards, such thyroid hormones
as chemical or radiation expo- Prenatal influences, such as
sure, lead exposure, passive maternal exposure to drugs or
inhalation of tobacco smoke, alcohol, severe maternal malnu-
and exposure to air, water, or trition, and maternal smoking
food contaminants Financial or socioeconomic
Genetic abnormalities hardships
Nutrition Sleep
Activity Coping
EXPECTED OUTCOMES
The child will
Grow and gain weight as expected on the basis of growth-chart
norms for age and gender.
Consume _____ calories and ___ml of fluids representing ____
servings (specify for each food group).
Achieve ____ hours of uninterrupted sleep daily.
Maintain age-appropriate activity level.
Parents will
Identify risk factors that may lead to disproportionate growth.
State understanding of preventive measures to reduce risk of dis-
proportionate growth.
Appetite; Body Image; Child Development: Middle Childhood
Growth; Risk Control; Weight: Body Mass
Determine: Monitor weight and height weekly to evaluate progress.
Monitor temperature, activity levels, sleep patterns, and changes
in nutritional status. Monitor prescribed and over-the-counter med-
ications taken. Determine exposure to tobacco smoke and/or other
environmental contaminants. These assessment parameters will assist
in developing appropriate interventions.
Perform: Weigh and measure the child weekly to evaluate progress.
Review growth-chart curve to compare with growth history.
165
Establish meal program that meets the childs nutritional needs.
Establish routine sleep schedule for the child. Help child keep a
chart to encourage increased levels of self-care.
List age-appropriate activities and exercises for the child to stimu-
late bone and muscle development and promote cardiovascular health.
Administer prescribed drugs and treatments as ordered. Ensure
that the child and parents understand the intended action and side
effects that may occur to ensure that therapy can continue without
interruption.
Provide an environment that is conducive to promote changes the
child must make. Environment can be a powerful motivator.
Inform: Educate child and parents on nutritional requirements for
childs age and gender. Discuss meals available to the child at home
to promote growth.
Teach child and parents about risk factors associated with dispro-
portionate growth, such as poor nutrition, lack of regular sleep,
environmental hazards, or lack of age-appropriate activities. Help to
identify preventive measures to be taken in the home to promote
continuity of care.
Attend: Encourage healthy, loving interactions between child and
other family members. Demonstrate healthy and positive interactions
with the child. Disproportionate growth may be associated with
emotional deprivation.
Encourage child and parents to express feelings about present
state of childs health. Listen attentively with understanding about
the self-esteem associated with what is considered by peers to be
other than normal. Parents will need help in supporting the child
through difficulties coping with normal peers.
Manage: If a medical or psychiatric illness places child at risk for dis-
proportionate growth, make sure child gets adequate follow-up med-
ical care and ensure that the care is appropriate and professional.
This will ensure the childs right to receive remedial and educational
care in accordance with his disability, as guaranteed by federal law.
If financial hardship interferes with the familys ability to provide
for child with disproportionate growth, offer a referral to a social
worker to improve the familys access to community resources.
Active Listening; Behavior Modification; Coping Enhancement;
Counseling; Nutritional Management; Patient Contracting; Weight
Management
Reference
Gregory, K. (2005, JanuaryFebruary). Update on nutrition for pre-term and
full term infants. Journal of Obstetric, Gynecology, and Neonatal Nursing,
34(1), 98108.
INEFFECTIVE HEALTH MAINTENANCE

DEFINITION
Inability to identify, manage, and/or seek out help to maintain health
Demonstrated lack of adaptive behaviors (internal or external
environmental changes)
Demonstrated lack of knowledge regarding basic health practices
History of lack of health-seeking behaviors
Reported or observed impairment of personal support systems
Reported or observed inability to take responsibility for meeting
basic health practices in any or all functional pattern areas.
Reported or observed lack of equipment or financial and other
resources
RELATED FACTORS
Cognitive impairment Diminished gross motor skills
Complicated grieving Inability to make appropriate
Deficient communication skills judgments
Diminished fine motor skills Ineffective family coping
Healthcare system Values and beliefs
EXPECTED OUTCOMES
The patient will
Maintain current health status.
Sustain no harm or injury.
Verbalize feelings and concerns.
Explain health maintenance program.
Identify available health resources.
Coping; Decision Making; Health Beliefs: Perceived Resources;
Health-Promoting Behavior; Social Support; Spiritual Health
Determine: Assess current health status; personal habits such as use
of tobacco, drugs, and alcohol; level of knowledge about disease
process; level of family and community assistance; coping
mechanisms and communication skills (verbal and written); and
degree of motivation to maintain health. Assessment factors will
assist the nurse in establishing interventions for this diagnosis.
Perform: Provide assistance with self-care, as needed. Encourage
increasing levels of independence. The patient should be as
independent in ADLs as possible.
167
Administer medications as prescribed to ensure continuation of
therapy.
Adapt environment to that which is best suited to the particular
patient. Reorient the patient as needed. In the disoriented patient,
reorientation should take place frequently to keep the person as
close to knowing person, place, and time as possible.
Provide a consistent caretaker whenever possible to promote sta-
bility for the patient.
Plan a health maintenance program for patient and family members
addressing current disabilities. Provide patient and family with a writ-
ten copy. Giving instructions in writing will reinforce the various
aspects of the program and increase the possibility of compliance.
Inform: Fully describe all aspects of the patients care to the family
to elicit cooperation from them in continuing a plan.
Instruct family members how to carry out health maintenance
practices. Demonstrate skills such as bathing, feeding, and reality
orientation; then, have family members return demonstration under
supervision. Involving family members allows them the opportunity
to perform skills and solve problems with support and supervision.
Provide specific instructions on how to maintain a safe
environment for the patient to avoid falls and other types of
accidental injuries.
Teach relaxation techniques (e.g., guided imagery, progressive mus-
cle relaxation, and meditation) that can be done by the patient and
the family to enhance coping ability and restore psychological and
physical equilibrium by decreasing autonomic response to anxiety.
Attend: Encourage patient and family to verbalize feelings and con-
cerns related to health maintenance. This promotes better
understanding and greater ease in managing challenging situations.
Demonstrate willingness to repeat instruction and demonstrate
skills needed to care for the patients until they feel comfortable.
Manage: Refer to social and community resources, such a stroke sup-
port group, and Alzheimers family support group. This helps the family
gain support and receive factual information. It provides opportunity to
express feeling in a group where others are experiencing similar issues.
Making referrals is appropriate to mental health professional to
assist with prevention of burnout for the family.
Anticipatory Guidance; Coping Enhancement; Counseling; Discharge
Planning; Health Education; Health System Guidance; Physician
Support; Referral; Support System Enhancement
Reference
Cole, C. S., et al. (2006, April). Assessment and discharge planning for the
older hospitalized adults with delirium. Medsurg Nursing, 15(2), 7176.
IMPAIRED HOME MAINTENANCE

DEFINITION
Inability to independently maintain a safe growth-promoting imme-
diate environment
Difficulty in maintaining home in a comfortable environment
Outstanding debts or financial crises
Request for assistance with home maintenance
Disorderly surroundings
Unwashed or unavailable cooking equipment, clothes, or linens
Accumulation of dirt, food wastes, or hygienic wastes
Offensive odors
Inappropriate household temperatures
Lack of necessary equipment or aids
Presence of vermin or rodents
RELATED FACTORS
Deficient knowledge Impaired functioning
Disease Insufficient finances
Inadequate support systems
Communication Roles/relationships
Knowledge
EXPECTED OUTCOMES
The patient and family members will
Express concern about poor home maintenance.
Verbalize plans to correct health and safety hazards in home.
Identify community resources available to help maintain home.
Family Functioning: Role Performance; Self-Care: IADLs
Determine: Assess home environment, financial resources, patients
knowledge about self-care; and communication patterns in the fam-
ily. Assessment information will assist in identifying appropriate
interventions.
Perform: List obstacles to effective home maintenance management
with patient and family to develop understanding of potential and
actual health and safety hazards. Begin discussions at patients level
of comfort. Adult learners learn best where they have specific needs
to fulfill.
Assist family members to assign daily and weekly responsibility
for home maintenance activities. Having a schedule will promote
consistency in following the plan of care.
169
Inform: Teach patient and family the importance of home
maintenance to ensure safety. Provide written materials on environ-
mental aspects of home maintenance.
Teach skills such as setting down and choosing from a list of
options, and assertiveness skills to enhance coping strategies. Help
patient and family develop a program by using relaxation strategies
(i.e., meditation, guided imagery, yoga, exercise) to reduce anxiety.
Attend: Encourage weekly discussions about progress in maintaining
home maintenance schedule to develop family unity and allow mem-
bers to address problems before they become overwhelming.
Manage: Assist family members to contact community agencies that
can assist them in their efforts to improve home maintenance man-
agement, such as self-help groups, cleaning services, and extermina-
tors. Community resources can lessen familys burden while
members learn to function independently.
Active Listening; Coping Enhancement; Counseling; Emotional
Support; Family Integrity Promotion; Family Support; Home
Maintenance Assistance
Reference
Horvath, K. J., et al. (2005, SeptemberOctober). Caregiver competence to
prevent home injury to the care recipient with dementia. Rehabilitation
Nursing, 30(5), 189196.
READINESS FOR ENHANCED HOPE

DEFINITION
A pattern of expectations and desires that is sufficient for mobilizing
energy on ones own behalf and can be strengthened
Expresses desire to enhance:
Ability to set personal goals
Belief in possibilities
Congruency of expectations with desires
Hope
Interconnectedness with others
Problem solving to meet goals
Sense of meaning to life
Spirituality
Behavior Roles/responsibilities
Emotional status
EXPECTED OUTCOMES
The patient will
Express desire for positive health outcomes.
Share personal goals to increase autonomy and personal
satisfaction.
Increase quality of life.
Plan to promote maximal physical, mental, social, and psychologi-
cal abilities.
Share strategies to live a meaningful life.
Express awareness of the need for developing and maintaining a
positive attitude of hope.
Seek spiritual support as needed.
Hope; Personal Well-Being; Quality of Life; Will to Live
Determine: Assess patients perception of ability to set personal goals.
Assess expression of desire to build on possibilities for the future,
and ability to align desires and expectations. Assess ability of patient
to maintain and enhance relationships with others. Assess patients
and familys spiritual needs, including religious beliefs and affiliation.
Information from assessment will assist in determining appropriate
interventions.
Perform: Schedule time to meet with family and patient to listen to
ways in which they plan to enhance their coping skills in the present
situation.
171
Facilitate opportunities for spiritual nourishment and growth to
address patients holistic needs for maximal therapeutic environment.
Inform: Teach self-healing techniques to both the patient and family,
such as meditation, guided imagery, yoga, and prayer, to promote
relaxation.
Teach patient how to incorporate the use of self-healing techniques
in carrying out usual daily activities. Practicing will increase the
chance that the patient will himself use these techniques.
that maximizes patients comfort. Comfort will reduce anxiety and
help patient cooperate with his or her treatment.
care.
Provide patient with concise information about patients condition.
Be aware of what the family members have already been told.
Attend: Reinforce familys efforts to care for the patient. Let them
Encourage family to support patients independence.
Encourage patients cooperation as you continue with healing
techniques, such as therapeutic touch. Cooperation will enhance the
effect of the therapy.
Provide emotional support to family and be available to answer
questions. Being available to answer questions and listen builds trust
of the family.
Manage: Refer family to community resources and support groups to
assist in managing patients illness and providing emotional and
financial assistance to caregivers.
Hope Facilitation; Self-Esteem Enhancement; Spiritual Growth Facili-
tation
Reference
Davidson, P. M., et al. (2007, JanuaryFebruary). Maintaining hope in transi-
tion: A theoretical framework to guide interventions for people with heart
failure. Journal of Cardiovascular Nursing, 22(1), 5864.
HOPELESSNESS
DEFINITION
Subjective state in which an individual sees few or no available alter-
natives or personal choices available and is unable to mobilize energy
on own behalf
Decreased appetite, affect, response to stimuli, verbalization
Increased or decreased sleep
Lack of involvement in self-care
Nonverbal cues, such as closing eyes, shrugging in response to
question, and turning away from speaker
Passivity and lack of initiative
RELATED FACTORS
Abandonment Lost belief in spiritual power
Deteriorating physical Lost belief in transcendent
condition power
Coping Values/beliefs
EXPECTED OUTCOMES
The patient will
Identify feelings of hopelessness regarding present situation.
Demonstrate more effective communication skills.
Resume appropriate rest and activity pattern.
Participate in self-care activities and decisions regarding care planning.
Use diversional activities.
Acceptance: Health Status; Adaptation to Physical Disability;
Depression Control; Hope; Quality of Life
Determine: Assess the following: nature of current medical diagnosis;
patients knowledge about medical diagnosis; actual or perceived
self-care deficits; mental status; communication patterns and support
systems; nutritional status and appetite; and sleep patterns. Also
monitor heart rate and blood pressure; respiratory rate, quality and
depth of respirations, and breath sounds. Assessment factors will
help identify appropriate interventions.
Perform: Follow medical regimen to manage the patients physiologic
condition. Build noncare-related time into the daily schedule to
allow time to develop a trusting relationship with the patient.
Provide comfort measures: adjust lighting and sound to minimize
irritating stimuli; offer back rubs and space procedures to promote
relaxation.
173
Inform: Keep patient informed about what to expect and when to
expect it. Accurate information reduces anxiety.
Teach self-healing techniques to both the patient and the family,
such as meditation, guided imagery, yoga, and prayer, to enhance
coping strategies. Teach patient how to incorporate the use of self-
healing techniques in carrying out usual daily activities.
Attend: Encourage patient to talk about personal assets and accom-
plishments and about improvements in his or her condition, no mat-
ter how small they may seem. Give positive feedback. Conversation
assists evaluation of patients self-concept and adaptive abilities.
Direct the patients focus beyond the present state. For example,
Your nasogastric tube will come out tomorrow and you will feel
more comfortable. This helps instill hope.
Encourage patient to talk about appropriate diversions and to
participate in them. Pleasurable activity decreases potential hazard
of crisis.
Manage: Refer patient and family to other professional caregivers,
for example, dietitian, social worker, clergy, mental health
professional, and support groups such as Ostomy Club, I Can Cope,
and Reach for Recovery. Assist patient to utilize appropriate
resources by contacting family and scheduling follow-up
appointments. These measures help give the patient a sense of direc-
tion and control over his or her future care.
Coping Enhancement; Decision-Making Support; Energy
Management; Mutual Goal Setting; Sleep Enhancement; Spiritual
Growth Facilitation; Support Group
Reference
Kronenwetter, C., et al. (2005, MarchApril). A qualitative analysis of inter-
views of men with early stage prostate cancer. Cancer Nursing, 28(2),
99107.
HYPERTHERMIA
DEFINITION
Body temperature elevated above normal range
Fever
Flushed, warm skin
Increased heart and respiratory rate
Seizures
RELATED FACTORS
Anesthesia Increased metabolic rate
Decreased perspiration Illness
Dehydration Medications
Exposure to hot environment Trauma
Inappropriate clothing Vigorous activity
Fluid and electrolytes Neurocognition
Pharmacological function Respiratory function
EXPECTED OUTCOMES
The patient will
Remain afebrile.
Maintain balance of intake and output within normal limits.
Maintain urine specific gravity between 1.005 and 1.015.
Exhibit moist mucous membranes.
Exhibit good skin turgor.
Remain alert and responsive.
Hydration; Infection Severity; Thermoregulation; Vital Signs
Determine: Monitor heart rate and rhythm, blood pressure, respira-
tory rate, LOC and level of responsiveness, and capillary refill time
every 14 hr to evaluate effectiveness of interventions and monitor
for complications.
Determine patients preferences for oral fluids, and encourage
patient to drink as much as possible, unless contraindicated. Moni-
tor and record intake and output, and administer intravenous fluids,
if indicated. Because insensible fluid loss increases by 10% for every
1.8 F (1 C) increase in temperature, patient must increase fluid
intake to prevent dehydration.
Perform: Take temperature every 14 hr to obtain an accurate core
temperature. Identify route and record measurements.
Administer antipyretics as prescribed and record effectiveness.
Antipyretics act on hypothalamus to regulate temperature.
175
Use nonpharmacologic measures to reduce excessive fever, such as
removing sheets, blankets, and most clothing; placing ice bags on
axillae and groin; and sponging with tepid water. Explain these
measures to patient. Nonpharmacologic measures lower body tem-
perature and promote comfort. Sponging reduces body temperature
by increasing evaporation from skin. Tepid water is used because
cold water increases shivering, thereby increasing metabolic rate and
causing temperature to rise.
Use a hypothermia blanket if patients temperature rises above
103 F (39.4 C), if ordered. Monitor vital signs every 15 min for
1 hr and then as indicated. Prolonged hyperthermia may lead to
complications such as seizures. Turn off blanket if shivering occurs.
Shivering increases metabolic rate, increasing temperature.
Manage: Report lack of responses to interventions to physician to
prevent complications.
Environmental Management; Fever Treatment; Fluid Management;
Temperature Regulation
Reference
Kayser-Jones, J. (2006, June). Preventable causes of dehydration: Nursing
home residents are especially vulnerable. American Journal of Nursing,
106(6), 45.
HYPOTHERMIA
DEFINITION
Body temperature below normal range
Body temperature below normal range
Cool, pale skin
Cyanotic nail beds
Increased blood pressure, heart rate, and capillary refill time
Piloerection
Shivering
RELATED FACTORS
Aging Exposure to cool environment
Consumption of alcohol Illness
Damage to hypothalamus Inactivity
Decreased ability to shiver Inadequate clothing
Decreased metabolic rate Malnutrition
Evaporation from skin in cool Medications
environment Trauma
Fluid and electrolytes Neurocognition
Pharmacological function Respiratory function
EXPECTED OUTCOMES
The patient will
Maintain body temperature within normal range.
Have warm and dry skin.
Maintain heart rate and blood pressure within normal range.
Not shiver.
Express feelings of comfort.
Show no complications associated with hypothermia, such as soft-
tissue injury, fracture, dehydration, and hypovolemic shock, if
warmed too quickly.
State an understanding of how to prevent further episodes of
hypothermia.
Neurological Status: Autonomic; Thermoregulation; Vital Signs
Determine: Monitor body temperature at least every 4 hr or more
frequently, if indicated, to evaluate effectiveness of interventions.
Record temperature and route to allow accurate data comparison.
Baseline temperatures vary, depending on route used. If temperature
drops below 95 F (35 C), use a low-reading thermometer to obtain
accurate reading.
177
Monitor and record neurologic status at least every 4 hr. Falling
body temperature and metabolic rate reduce pulse rate and blood
pressure, which reduces blood perfusion to brain, resulting in disori-
entation, confusion, and unconsciousness.
Monitor and record heart rate and rhythm, blood pressure, and
respiratory rate at least every 4 hr. Blood pressure and pulse
decrease in hypothermia. During rewarming, patient may develop
hypovolemic shock. During warming, ventricular fibrillation and car-
diac arrest may occur, possibly signaled by irregular pulse.
Perform: Provide supportive measures, such as placing patient in
warm bed and covering with warm blankets, removing wet or con-
strictive clothing, and covering metal or plastic surfaces that contact
patients body. These measures protect patient from heat loss.
Follow prescribed treatment regimen for hypothermia: As ordered,
administer medications to prevent shivering to avoid overheating.
Monitor and record effectiveness. As ordered, administer analgesic
to relieve pain associated with warming. Monitor and record effec-
tiveness.
Use hyperthermia blanket to warm patient if temperature drops
below 95 F (35 C). Warm patient to 97 F (36.1 C).
As appropriate, administer fluids during rewarming to prevent
hypovolemic shock. If administering large volumes of intravenous
fluids, consider using a fluid warmer to avoid heat loss.
Inform: Discuss precipitating factors with patient, if indicated.
Patient may require community outreach assistance with certain pre-
cipitating factors, including inadequate living conditions, insufficient
finances, and abuse of medications (such as sedatives and alcohol).
Instruct patient in precautionary measures to avoid hypothermia,
such as dressing warmly even when indoors, eating proper diet, and
remaining as active as possible. Precautions help to prevent acciden-
tal hypothermia.
Manage: Report lack of responses to interventions to physician to
prevent complications.
Comfort Level; Fluid Management; Hypothermia Treatment;
Temperature Regulation; Vital Signs Monitoring
Reference
Good, K. K., et al. (2006, May). Postoperative hypothermiaThe chilling
consequences. AORN Journal, 83(5), 10551066.
DISTURBED PERSONAL IDENTITY

DEFINITION
Inability to maintain an integrated and complete perception of self
Disturbed body image Contradictory personal traits
Fluctuating feelings about self Ineffective role performance
Gender confusion Ineffective coping
Unable to distinguish between Uncertainty about ideological
inner and outer stimuli and cultural values
Delusional description of self Uncertainty about goals
Feelings of emptiness Disturbed relationships
Feelings of strangeness
RELATED FACTORS
Organic brain syndrome Situational crisis
Dissociative identity disorder Dysfunctional family processes
Psychiatric disorders Cultural discontinuity
Low self-esteem Cult indoctrination
Manic states Discrimination or prejudice
Social role change Use of psychoactive drugs
Stage of growth Ingestion of toxic chemicals
States of development Inhalation of toxic chemicals
Safety Sexual practices
Mental status Cultural beliefs
Self-care Relationships
EXPECTED OUTCOMES
The patient will
Contract for safety.
Identify internal versus external stimuli.
Maintain adequate nutritional intake.
Identify personal goals and realistic steps toward those goals.
Compile a list of resources to call when needed.
Remain free from substance abuse.
Secure a safe place to live in.
Coping; Distorted Thought; Impulse self-Control; Self-Control;
Self-Esteem
Determine: Assess for suicidal/homocidal ideation, self-induced cuts
or burns. Assess for self-induced vomiting or restricting of food.
Thorough mental status examination. Individuals struggling with
identified issues are at an increased safety risk.
179
Monitor mental status daily to be able to intervene if necessary.
Monitor weight weekly to be able to detect changes that may
require further intervention.
Perform: Contract with patient for safety. Schedule meetings with
patient to process feelings and experiences. Demonstrating care and
compassion for the patient allows him or her to feel safe and pro-
motes healing.
Inform: Instruct patient to journal feelings and list coping strategies.
Journaling can help a patient maintain self-control and may increase
insight.
Attend: Accept patient in his or her struggle. Reinforce taking
healthy risks and appropriate expression of feelings. Appropriate
expression of feelings enhances self-esteem and promotes resiliency.
Manage: Refer patients to mental health services for medication and
symptom management. Disturbed personal identity may require
ongoing mental health care.
Coping Enhancement; Environmental Management: Safety; Role
Enhancement; Self-Esteem Enhancement
Reference
Boyd, M. A. (2008). Psychiatric nursing. Philadelphia: Lippincott Williams &
Wilkins.

IMMUNIZATION STATUS
DEFINITION
A pattern of conforming to local, national, and/or international stan-
dards of immunization to prevent infectious disease(s) that is sufficient
to protect a person, family, or community and can be strengthened
Expresses desire to enhance
Behavior to prevent infectious disease.
Identification of possible problems associated with immunizations.
Identification of providers of immunizations.
Immunization status.
Knowledge of immunization standards.
Record keeping of immunizations.
Healthcare system
Self-perception
EXPECTED OUTCOMES
The patient will
Express knowledge of health-seeking behaviors necessary to partic-
ipate in immunization.
Demonstrate adherence behavior to standard recommended immu-
nization protocols.
Develop an ongoing plan for maintaining records of
immunizations.
Community Health Status: Immunity; Community Risk Control:
Communicable Disease; Immunization Behavior; Knowledge:
Infection
Determine: Assess patients prior participation in immunization pro-
gram. Determine patients perception of the need for the prevention
of infectious diseases and responsibility for controlling the spread
of communicable disease. Assess patients attitude toward health-
seeking behavior that leads to immunization and knowledge of
infection control through immunization for communicable disease.
Assessment factors help in determining appropriate interventions.
Perform: Administer vaccines, as ordered, to ensure expected result
will occur. Implement a mechanism or device for record keeping
of immunizations to prevent gaps and overlaps in patient immuniza-
tions.
Inform: Help patient understand possible risks associated with immu-
nizations to assist patients identify reportable risks and
complications resulting from immunizations.
181
Attend: Encourage patients to have immunizations as close to due
dates as possible to ensure that protection from disease will be con-
sistent and continuous.
Listen attentively to what patient has to say about fear of vaccines.
Fear is often the factor that keeps people from being vaccinated.
Manage: Request for a case manager to make a home visit to help
prepare the family for the patients return to a safe environment.
Refer patient to community resources that may offer assistance to
the patient when needed.
Offer written information that can be referred to when needed.
Communicable Disease Management; Immunization/Vaccination
Management; Infection Control
Reference
Wiggs-Stayner, K. S., et al. (2006, August). The impact of mass school immu-
nization on school attendance. Journal of School Nursing, 22(4), 922.
FUNCTIONAL URINARY INCONTINENCE

DEFINITION
Inability of usually continent person to reach toilet in time to avoid
unintentional loss of urine
Amount of time needed to reach toilet exceeding length of time
between sensing urge to void and uncontrolled voiding
Loss of urine before reaching toilet
May be incontinent only in the morning
Able to empty bladder completely
RELATED FACTORS
Altered environmental factors Psychological factors
Impaired cognition Weakened supporting pelvic
Impaired vision structures
Neuromuscular limitations
Behavior Physical regulation
Elimination Self-care
EXPECTED OUTCOMES
The patient will
Void at appropriate intervals.
Have minimal, if any, complications.
Demonstrate skill in managing incontinence.
Discuss impact of incontinence on him and family members.
Identify resources to assist with care following discharge.
Coordinated Movement; Self-Care: Toileting; Symptom Control;
Urinary Continence; Urinary Elimination
Determine: Monitor and record patients voiding patterns to ensure
correct fluid replacement therapy.
Perform: Stimulate patients voiding reflexes (give patient drink of
water while on toilet, stroke area over bladder, or pour water over
perineum) to trigger bladders spastic reflex. Provide hyperactive
patient with distraction, such as a magazine, to occupy attention
while on toilet, reduce anxiety, and ease voiding.
Maintain adequate hydration up to 3,000 ml daily, unless
contraindicated. Scheduling fluid intake promotes regular bladder
distention and optimal time intervals between voidings. Limit fluid
intake to 150 ml after dinner to reduce need to void at night.
Assist with specific bladder elimination procedures, such as the
following: bladder trainingthis involves muscle-strengthening
183
exercises, adequate fluid intake, and carefully scheduled voiding
times (encourage voiding every 2 hr while awake and once during
night); rigid toilet regimenplace patient on toilet at specific inter-
vals (every 2 hr or after meals) and note whether voiding occurred
at each interval (this helps patient adapt to routine physiologic func-
tion); behavior modificationrefrain from punishing unwanted
behavior (e.g., voiding in wrong place), and reinforce positive behav-
ior using social or material rewards (this helps patient learn alterna-
tives to maladaptive behaviors); use of external catheterapply
according to established procedure and maintain patency, observe
condition of perineal skin and clean with soap and water at least
twice daily (this ensures effective therapy and prevents infection and
skin breakdown); application of protective pads and garmentsuse
only when interventions have failed to prevent infection and skin
breakdown and allow at least 46 weeks for trial period (establish-
ing continence requires prolonged effort).
Maintain continence based on patients voiding patterns and limita-
tions. Respond to call light promptly to avoid delays in voiding routine.
Orient patient to toileting environment: time, place, and activity
to offer security. Provide privacy and adequate time to void to allow
patient to void easily without anxiety.
Replace wet clothes immediately. Select clothing that promotes
easy dressing and undressing (e.g., Velcro fasteners and gowns) to
reduce patients frustration with voiding routine.
Inform: Teach family members and support personnel to reduce anxi-
ety that results from noninvolvement. Instruct patient and family
members on continence techniques to use at home to increase
chances of successful bladder retraining.
Attend: Encourage patient and family members to share feelings
related to incontinence. This allows specific problems to be identified
and resolved. Attentive listening conveys recognition and respect.
Manage: Refer patient/family to home healthcare agency, or support
group to provide access to additional community resources.
Pelvic Muscle Exercise; Prompted Voiding; Self-Care Assistance; Uri-
nary Elimination Management; Urinary Habit Training
References
Dowd, T., & Dowd, E. T. (2006, JanuaryFebruary). A cognitive therapy
approach to promote continence. Journal of Wound, Ostomy and
Continence Nursing, 33(1), 6368.
Zarowitz, B. J., & Ouslander, J. G. (2006, SeptemberOctober). Management
of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265270.
OVERFLOW URINARY INCONTINENCE

DEFINITION
Involuntary loss of urine associated with overdistention of the bladder
Bladder distention
High postvoid residual volume
Nocturia
Reported and observed involuntary leakage of small volumes of
urine
RELATED FACTORS
Bladder outlet obstruction Severe pelvic prolapse
Detrusor external sphincter Side effects of anticholinergic,
dyssynergia calcium channel blocker, or
Detrusor hypocontractility decongestant medications
Fecal impaction Urethral obstruction
EXPECTED OUTCOMES
The patient will
Void 200300 mL of clear, yellow urine every 34 hr while
awake.
Have postvoid residual of less than 50 ml.
Have reduction in urinary incontinence episodes or complete
absence of urinary incontinence.
Experience relief of most bothersome aspect of urinary
incontinence.
Remain clean and dry without urine odor.
Express understanding of condition and activities to prevent/reduce
overflow incontinence.
Express improvement in quality of life.
Knowledge: Treatment Regimen; Urinary Continence
Determine: Monitor and record patients voiding patterns to
determine existence and extent of overflow incontinence.
Monitor and record patients intake and output to determine fluid
balance.
Perform: Ask patient to keep a bladder diary of continent and incon-
tinent voids to promote understanding of the extent of the problem
of overflow incontinence. Discuss voiding and fluid intake patterns.
Accurate understanding of patients pattern provides a baseline for
introducing new activities.
185
Provide privacy and adequate time to void to decrease anxiety
and promote relaxation of sphincter.
Assist patient to assume usual position for voiding. Some patients
are unable to void while lying in bed and may develop urinary
retention and overflow incontinence.
Massage (cred) the bladder area during urination to increase
pressure in the pelvic area to encourage drainage of urine from the
bladder.
Institute indwelling or intermittent catheterization, as ordered.
Catheterization is used as a last resort to empty the bladder prevent-
ing overflow incontinence.
Assist with application of pads and protective garments (used only
as a last resort) to prevent skin breakdown and odor and to
promote social acceptance.
Inform: Teach patient and/or family to catheterize patient with
chronic overflow incontinence related to urinary retention using
clean technique to manage long-term overflow incontinence.
Teach stress management and relaxation techniques. Stress and
anxiety interfere with sphincter relaxation, causing urinary retention
and overflow incontinence.
Attend: Encourage patient to share feelings related to incontinence to
reduce anxiety.
Encourage patient to drink six to eight glasses of noncaffeinated,
nonalcoholic, and noncarbonated liquid, preferably water, per day
(unless contraindicated). 1,5002000 mL/day promotes optimal renal
function and flushes bacteria and solutes from the urinary tract.
Caffeine and alcohol promote diuresis and may contribute to excess
fluid loss and irritation of the bladder wall.
Encourage patient to respond to the urge to void in a timely man-
ner. Ignoring the urge to urinate may cause incontinence.
Encourage patient to participate in regular exercise, including
walking and modified sit-ups (unless contraindicated). Weak abdomi-
nal and perineal muscles weaken bladder and sphincter control.
Encourage patient to avoid anticholinergics, opioids, psychotrop-
ics, -adrenergic agonists, -adrenergic agonists, and calcium-
channel blockers (unless contraindicated), which inhibit relaxation of
the urinary sphincter and cause urinary retention.
Manage: Provide referrals for physical therapy or psychological
counseling as necessary to enhance success.
Urinary Incontinence Care; Urinary Retention Care
Reference
DuBeau, C. (2006). Clinical presentation and diagnosis of urinary
incontinence. Retrieved December 12, 2006, from http://www.uptodate.com
REFLEX URINARY INCONTINENCE

DEFINITION
Involuntary loss of urine at somewhat predictable intervals when a
specific bladder volume is reached
Complete emptying (with lesion above pontine micturition center)
or incomplete emptying (with lesion above sacral micturition
center) of bladder
Either inability to sense full bladder, urge to void, or voiding, or
ability to sense urge to void without ability to voluntarily inhibit
bladder contraction
Inability to voluntarily inhibit or initiate voiding
Predictable pattern of voiding
Sensations associated with full bladder (sweating, restlessness, and
abdominal discomfort)
RELATED FACTORS
Tissue damage (e.g., radiation therapy)
Neurological impairment above level of pontine or sacral micturi-
tion center
EXPECTED OUTCOMES
The patient will
Maintain fluid balance, with intake approximately equaling output.
Achieve urinary continence.
Demonstrate skill in managing urinary incontinence.
Discuss impact of incontinence on himself and family.
Knowledge: Treatment Regimen; Nutritional Status: Food & Fluid
Intake; Tissue Integrity: Skin & Mucous Membranes; Urinary Conti-
nence; Urinary Elimination
Determine: Monitor intake and output to ensure correct fluid
replacement therapy. Report output greater than intake.
Perform: Implement and monitor effectiveness of specific bladder
elimination procedure, such as the following:
Stimulate reflex arc. Patient who voids at somewhat predictable
intervals may be able to regulate voiding by reflex arc stimulation. Trig-
ger voiding at regular intervals (e.g., every 2 hr) by stimulating skin of
abdomen, thighs, or genitals to initiate bladder contractions. Avoid
187
stimulation at nonvoiding times. Stimulate primitive voiding reflexes by
giving patient water to drink while he sits on toilet or pouring water
over perineum. External stimulation triggers bladders spastic reflex.
Apply external catheter according to established procedure and
maintaining patency. Observe condition of perineal skin and clean
with soap and water at least twice daily. Cleanliness prevents skin
breakdown and infection. External catheter protects surrounding
skin, promotes accurate output measurement, and keeps patient dry.
Applying foam strip in spiral fashion increases adhesive surface and
cuts risk of impaired circulation.
Insert indwelling catheter. Monitor patency and keep tubing free
from kinks to avoid drainage pooling and ensure accurate therapy. Keep
drainage bag below level of bladder to avoid urine reflux into bladder.
Perform catheter care according to established procedure. Maintain
closed drainage system to prevent bacteriuria. Secure catheter to leg
(female) or abdomen (male) to avoid tension on bladder and sphincter.
Apply suprapubic catheter. Change dressing according to estab-
lished procedure to avoid skin breakdown. Monitor patency and
keep tubing free from kinks to avoid drainage pooling in loops of
catheter. Keep drainage bag below bladder level to avoid urine reflux
into bladder. Maintain closed drainage system to prevent bacteriuria.
Change wet clothes to prevent patient from becoming
accustomed to wet clothes.
Inform: Instruct patient and family members on continence
techniques to use at home. Have patient and family members return
demonstrations until they can perform procedure well. Patient edu-
cation begins with assessment and depends on nurses therapeutic
relationship with patient and family.
Attend: Encourage high fluid intake (3,000 ml daily, unless
contraindicated) to stimulate micturition reflex. Limit fluid intake
after 7 p.m. to prevent nocturia.
Encourage patient and family members to share feelings and con-
cerns regarding incontinence. A trusting environment allows nurse to
make specific recommendations to resolve patients problems.
Manage: Refer patient and family members to psychiatric liaison
nurse, home healthcare agency, support group, or other resources, as
appropriate. Community resources typically provide healthcare not
available from other healthcare agencies.
Pelvic Muscle Exercise; Urinary Bladder Training; Urinary Elimina-
tion Management; Urinary Incontinence Care
Reference
Zarowitz, B. J., & Ouslander, J. G. (2006, SeptemberOctober). Management
of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265270.
STRESS URINARY INCONTINENCE

DEFINITION
Sudden leakage of urine with activities that increase intra-abdominal
pressure
Dribbling with increased abdominal pressure
Frequency
Urgency
RELATED FACTORS
Degenerative changes in pelvic Intrinsic urethral sphincter
muscles deficiency
High intra-abdominal pressure Weak pelvic muscles
EXPECTED OUTCOMES
The patient will
Maintain continence.
State increased comfort.
State understanding of treatment.
State understanding of surgical procedure.
Demonstrate skill in managing urinary elimination problems.
Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;
Urinary Elimination
Determine: Observe patients voiding patterns, time of voiding,
amount voided, and whether voiding is provoked by stimuli. Accu-
rate, thorough assessment forms basis of an effective treatment plan.
Perform: Provide appropriate care for patients urologic condition,
monitor progress, and report patients responses to treatment.
Patient expects to receive adequate care and to participate in
decisions regarding care.
Help patient to strengthen pelvic floor muscles by Kegel exercises
for sphincter control. Exercises increase muscle tone and restore cor-
tical control.
Promote patients awareness of condition through education to
help patient understand illness as well as treatment.
Help patient reduce intra-abdominal pressure by losing weight,
avoiding heavy lifting, and avoiding chairs or beds that are too high
189
or too low. These measures reduce intra-abdominal pressure and
bladder pressure.
Provide supportive measures:
Respond to call bell quickly, assign patient to bed next to bath-
room, put night-light in bathroom, and have patient wear easily
removable clothing (gown rather than pajamas and Velcro fasteners
rather than buttons or zippers). Early recognition of problems pro-
motes continence; easily removed clothing reduces patient frustration
and helps achieve continence.
Provide privacy during toileting to reduce anxiety and promote
elimination.
Have patient empty bladder before meals, at bedtime, and
before leaving accessible bathroom area to promote elimination,
avoid accidents, and help relieve intra-abdominal pressure.
Limit fluids to 150 ml after dinner to reduce need to void at
night.
Encourage high fluid intake, unless contraindicated, to moisten
mucous membranes and maintain hydration.
Suggest patient eat increased amount of salty food before going
on a long trip (unless contraindicated). Increased sodium decreases
urine production.
Make protective pads available for patients undergarments, if
needed, to absorb urine, protect skin, and control odors.
If surgery is scheduled, give attentive, appropriate preoperative
and postoperative instructions and care to reduce patients anxiety
and build trust in caregivers.
Inform: Alert patient and family members about need for toilet
schedule. Prepare for discharge according to individual needs to
ensure that patient will receive proper care.
Attend: Encourage patient to express feelings and concerns related to
urologic problems. This helps patient focus on specific problem.
nurse, support group, or other resources, as appropriate.
Community resources typically provide healthcare not available from
other healthcare agencies.
Pelvic Muscle Exercise; Teaching: Individual; Urinary Elimination
Management; Urinary Habit Training; Urinary Incontinence Care
Reference
Anders, K. (2006, May). Recent developments in stress urinary incontinence in
women. Nursing Standard, 20(35), 4854.
URGE URINARY INCONTINENCE

DEFINITION
Involuntary passage of urine occurring shortly after a strong sense
of urgency to void
Bladder contraction or spasm Increased or decreased volume
Frequency Nocturia
Inability to reach toilet in time Urgency
RELATED FACTORS
Alcohol intake Decreased bladder capacity
Atrophic urethritis Detrusor hyperactivity with
Atrophic vaginitis impaired bladder contractility
Bladder infection Fecal impaction
Caffeine intake Use of diuretics
EXPECTED OUTCOMES
The patient will
Have fewer episodes of incontinence.
State understanding of treatment.
Discuss impact of disorder on himself and family members.
Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;
Urinary Elimination
Determine: Observe voiding pattern; document intake and output.
This ensures correct fluid replacement therapy and provides informa-
tion about patients ability to void adequately.
Perform: Provide appropriate care for patients urologic condition,
monitor progress, and report patients responses to treatment.
Patient should receive adequate care and take part in decisions
about care as much as possible.
Assist with specific bladder elimination procedures, such as the
following:
bladder trainingplace patient on commode every 2 hr while
awake and once during night, provide privacy, and gradually
increase intervals between toileting (these measures aim to restore a
regular voiding pattern). As well as rigid toilet regimenplace
patient on toilet at specific times (to aid adaptation to routine
191
physiologic function), and keep baseline micturition record for
37 days (to monitor toileting effectiveness).
Administer pain medication; discuss effectiveness with patient to
reinforce that pain can be alleviated, which reduces tension and anxiety.
Place commode next to bed, or assign patient bed next to
bathroom. A bedside commode or convenient bathroom requires less
energy expenditure than bedpan. If using commode, keep bed and
commode at same level to facilitate patients movements. If using
bathroom, provide good lighting from bed to bathroom to reduce
sensory misinterpretation; remove all obstacles between bed and bath-
room to reduce chance of falling. Prepare pleasant toilet environment
that is warm, clean, and free from odors to promote continence.
Provide a clock to help patient maintain voiding schedule through
self-monitoring.
Unless contraindicated, maintain fluids to 3,000 ml daily to mois-
ten mucous membranes and ensure hydration; limit patient to 150
ml after dinner to reduce need to void at night.
Have patient wear easily removable clothes (gown instead of paja-
mas and Velcro fasteners instead of buttons or zippers) to reduce
frustration and delay in voiding routine.
If patient loses control on way to bathroom, instruct patient to
stop and take a deep breath. Anxiety and rushing may strengthen
bladder contractions.
Inform: Explain urologic condition to patient and family members;
include instructions on preventive measures and established bladder
schedule. Patient education begins with educational assessment and
depends on establishing a therapeutic relationship with patient and
family. Prepare patient for discharge according to individual needs to
allow patient to practice under supervision.
Instruct patient and family members on continence techniques for
home use. This reduces fear and anxiety resulting from lack of knowl-
edge of patients condition and reassures patient of continuing care.
Attend: Encourage patient to express feelings and concerns related to
his or her urologic problem to identify patients fears.
nurse, support group, or other resources, as appropriate.
Community resources typically provide healthcare not available from
other healthcare agencies.
Fluid Monitoring; Perineal Care; Self-Care Assistance: Toileting; Uri-
nary Elimination Management; Urinary Habit Training; Urinary
Incontinence Care
Reference
Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary
continence in hospitalized older people?: An exploratory study. Journal of
Clinical Nursing, 15(10), 12761286.
RISK FOR URGE URINARY INCONTINENCE

DEFINITION
At risk for involuntary loss of urine associated with a sudden,
strong sensation or urinary urgency
RISK FACTORS
Effects of medication, caffeine, Detrusor muscle instability
or alcohol with impaired contractility
Detrusor hyperreflexia from Ineffective toileting habits
cystitis, urethritis, tumors, Involuntary sphincter
renal calculi, central nervous relaxation
system disorders above Small bladder capacity
pontine micturation center
EXPECTED OUTCOMES
The patient will
State ability to anticipate if incontinence is likely to occur.
State understanding of potential causes of urge incontinence and
its treatment.
Avoid or minimize complications of urge incontinence.
Discuss potential effects of urologic dysfunction on self and family
members.
Identify community resources to cope with alterations in urinary
status.
Knowledge: Treatment Regimen; Urinary Continence; Urinary Elimi-
nation
Determine: Observe patients voiding pattern, and document intake
and output to ensure correct fluid replacement therapy and provide
information about the patients ability to void adequately.
Determine patients premorbid elimination status to ensure that inter-
ventions are realistic and based on the patients health status and goals.
Assess patients ability to sense and communicate elimination
needs to maximize self-care.
Perform: Unless contraindicated, provide 212 to 3 qt (2.53 L) of
fluid daily to moisten mucous membranes and ensure adequate
hydration. Space out fluid intake through the day and limit it to
150 ml after supper to reduce the need to void at night.
Place commode next to bed, or assign patient bed next to
bathroom. A bedside commode or convenient bathroom requires less
193
energy expenditure than bedpan. If using commode, keep bed and
commode at same level to facilitate patients movements. If using
bathroom, provide good lighting from bed to bathroom to reduce
sensory misinterpretation; remove all obstacles between bed and bath-
room to reduce chance of falling. Prepare pleasant toilet environment
that is warm, clean, and free from odors to promote continence.
Have patient wear easily removed articles of clothing (a gown
instead of pajamas, Velcro fasteners instead of buttons or zippers)
to facilitate the removal of clothing and foster independence.
Have patient keep a diary recording episodes of incontinence to
use as a basis for planning bladder training interventions; interven-
tions may include voiding every 2 hr, avoiding high fluid intake,
maintaining proper hygiene, or notifying a healthcare professional if
urge incontinence occurs frequently. Individualized interventions help
promote self-care, foster motivation, and avoid incontinence.
Incorporate patients suggestions for managing incontinent
episodes into a care plan to foster motivation.
Inform: Explain urge incontinence to patient and family members,
especially preventive measures and potential underlying causes, to
foster compliance.
Instruct patient to stop and take a deep breath if he or she expe-
riences an intense urge to urinate before he can reach a bathroom.
Anxiety and rushing may increase bladder contraction.
Attend: Encourage patient to express feelings about incontinence to
provide emotional support and identify needed areas for further
patient teaching.
Manage: Use an interdisciplinary approach to caring for incontinence.
Incorporate recommendations from a urologist, urology nurse special-
ist, other healthcare providers, and the patient. Monitor progress and
report the patients response to interventions. An interdisciplinary
approach helps ensure that the patient receives adequate care. Encour-
aging patient participation on the team will help foster motivation.
Note if patient expresses concern about the effect of incontinence
on sexuality. If appropriate, refer him to a sex therapist to promote
sexual health.
Refer patient and family members to community resources such as
support groups, as appropriate, to help ensure continuity of care.
Fluid Monitoring; Urinary Elimination Management; Urinary Habit
Training; Urinary Incontinence Care
Reference
Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary
continence in hospitalized older people? An exploratory study. Journal of
DISORGANIZED INFANT BEHAVIOR

DEFINITION
Disintegrated physiological and neurobehavioral responses of infant
to the environment
Attentioninteraction systemabnormal response to sensory stimuli
(e.g., difficulty soothing, inability to sustain alert status)
Motor-systemaltered primitive reflexes; finger splaying; jittery,
uncoordinated movement; increased or decreased tone; startles,
tremors, or twitches
Physiologicalarrhythmias, bradycardia, or tachycardia; desatura-
tion; feeding intolerances; skin color changes
Regulatory problemsinability to inhibit startle; irritability
State-organizational systemactive or quiet awake; diffuse sleep
RELATED FACTORS
CaregiverCue knowledge Postnatalfeeding intolerance;
deficit; cue misreading; environ- invasive procedures; malnutri-
mental stimulation contribution tion; motor and/or oral prob-
Environmentalphysical envi- lems; pain; prematurity
ronment inappropriateness; Prenatalcongenital or genetic
sensory deprivation, inappro- disorders; teratogenic exposure
priateness, or overstimulation
Individualgestational or
postconceptual age; illness;
immature neurological system
Elimination Role/relationships
Neurocognition Sensation/perception
Physical regulation
EXPECTED OUTCOMES
The parents will
Learn to identify and understand infants behavioral cues.
Identify their own emotional responses to infants behavior.
Identify means to help infant overcome behavioral disturbance.
Identify ways to improve their ability to cope with infants
responses.
Express positive feelings about their ability to care for infant.
Identify resources for help with infant.
The infant will
Begin to show appropriate signs of maturation.
Knowledge: Infant Care; Mobility; Neonate; Neurological Status;
Preterm Infant Organization; Sleep Thermoregulation
195
Determine: Monitor infants responses to ensure effectiveness of pre-
ventive measures
Inform: Explain to parents that infant maturation is a developmental
process. Their participation is crucial to help them understand the
importance of nurturing the infant.
Explain to parents that their actions can help modify some of
infants behavior; however, make it clear that infant maturation isnt
completely within their control. This explanation may help decrease
the parents feelings of incompetence.
Explain to parents that infant gives behavioral cues that indicate
needs. Discuss appropriate ways to respond to behavioral cuesfor
example, providing stimulation that doesnt overwhelm the infant;
stopping stimulation when the infant gives behavioral cues (such as
yawning, looking away, or becoming agitated); and finding methods
to calm the infant if she becomes agitated (such as swaddling, gentle
rocking, and quiet vocalizations). Monitoring responses aids in gaug-
ing effectiveness of meeting needs.
Help parents identify and cope with their responses to infants
behavioral disturbance to help them recognize and adjust their
response patterns. When the infant doesnt respond positively, the
parents may feel inadequate or become frustrated. They need to
understand that these reactions are normal.
Attend: Explore with parents ways to cope with stress imposed by
infants behavior to help them develop better coping skills.
Praise parents when they demonstrate appropriate methods of
interacting with the infant to provide positive reinforcement.
Manage: Provide parents with information on sources of support
and special infant services to promote coping with infants long-term
needs.
Environmental Management; Neurologic Monitoring; Newborn
Care; Parent Education: Infant; Positioning; Sleep Enhancement
Reference
Beal, J. A. (2005, NovemberDecember). Evidence for best practices in the
neonatal period. The American Journal of Maternal Child Nursing, 30(6),
397403.
RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION
Risk for alteration in integration and modulation of the physiologi-
cal and behavioral systems of functioning (such as autonomic,
motor, state-organizational, self-regulatory, and attentionalinterac-
tional systems)
RISK FACTORS
Environmental overstimulation Oral or motor problems
Invasive or painful procedures Pain
Lack of containment or Prematurity
boundaries
Physical regulation
EXPECTED OUTCOMES
The parents will
Identify factors that place infant at risk for behavioral disturbance.
Identify potential signs of behavioral disturbance in infant.
Identify appropriate ways to interact with infant.
Identify their reactions to infant (including ways of coping with
occasional frustration and anger).
The infant will
Maintain physiologic stability.
Maintain an organized motor system.
Respond to sensory information in an adaptive way.
Knowledge: Child Development: 1 Month, 2 Months, 4 Months,
6 Months, and 12 Months; Infant Care; Neurological Status;
Knowledge: ParentInfant Attachment; Parenting; Preterm Infant
Organization; Sleep
Determine: Monitor infants responses to ensure effectiveness of pre-
ventive measures.
Perform: Demonstrate appropriate ways of interacting with the
infant to help parents identify and interpret the infants behavioral
cues and respond appropriately. For example, help them recognize
when the infant is awake and alert, and help them understand
when the infant needs more stimulation, such as being spoken to
or held.
197
process and that their participation is crucial to their understanding
of the importance of nurturing the infant. Participation in the
process by the parents will both stimulate the developmental process
and alert to delays in development.
Explain to parents that their actions can help modify some of
their infants behavior; however, make it clear that infant maturation
isnt completely within their control. This explanation may decrease
the parents feelings of incompetence.
Explain to parents that certain risk factors may interfere with the
infants ability to achieve optimal development. These risk factors
include overstimulation, lack of stimulation, lack of physical contact,
and painful medical procedures. Educating the parents will help
them understand their role in interpreting the infants behavioral
cues and providing appropriate stimulation.
Describe for the parents the potential signs of a behavioral distur-
bance in the infant: inappropriate responses to stimuli, such as the
failure to respond to human contact or tendency to become agitated
with human contact; physiologic regulatory problems, such as a
breathing disturbance in a premature infant; and apparent inability
to interact with the environment. Education will help the parents
recognize if the infant has a problem in behavioral development.
Attend: Explore with parents ways to cope with the stress imposed
by the infants behavior to increase their coping skills. Help parents
identify their emotional responses to the infants behavior to help
them recognize and adjust their response patterns. Explain that it is
normal for parents to experience feelings of inadequacy, frustration,
or anger if the infant does not respond positively to them.
Praise the parents when they demonstrate appropriate methods of
interacting with the infant to provide positive reinforcement.
Manage: Provide the parents with information on sources of support
and special infant services to help them cope with the infants long-
term needs.
Attachment Process, Infant Care; Newborn Monitoring; Parent
Education: Infant; Positioning; Surveillance
Reference
Swartz, M. K. (2005, MarchApril). Parenting preterm infants: A meta-
synthesis. The American Journal of Maternal Child Nursing, 30(2),
115120.
READINESS FOR ENHANCED ORGANIZED

INFANT BEHAVIOR
DEFINITION
A pattern of modulation of the physiologic and behavioral systems
of functioning (such as autonomic, motor, state-organizational, self-
regulatory, and attentionalinteractional systems) in an infant that is
satisfactory but that can be improved
Use of some self-regulatory behaviors
Definite sleepwake states
Responsiveness to visual and auditory stimuli
Stable physiologic measures
RELATED FACTORS
Pain
Immaturity
Physical regulation
EXPECTED OUTCOMES
The parents will
Express understanding of their role in infants behavioral develop-
ment.
Express confidence in their ability to interpret infants behavioral
cues.
Identify means to promote infants behavioral development.
The infant will
Maintain physiologic stability.
Maintain an organized motor system.
Respond to information in an adaptive way.
Knowledge: Child Development: 1, 2, 4, 6, and 12 Months; Infant
Care; Neurological Status; Sleep
Determine: Monitor infants responses to ensure effectiveness of
preventive measures.
Perform: Demonstrate appropriate ways of interacting with the
infant, such as moderate stimulation, gentle rocking, and quiet
vocalizations, to help the parents identify the most effective methods
of interacting with their child.
199
process. Further explain that infants exhibit three behavioral states:
sleeping, crying, and being awake and alert. Also explain that
infants provide behavioral cues that indicate their needs. Education
will help parents understand the importance of nurturing the infant
and prepare them to respond to the infants behavioral cues.
Explain to parents that their actions can help promote infant
development. Make it clear, however, that infant maturation isnt
completely within their control. Explanation may decrease feelings
of anxiety and incompetence and help prevent unrealistic
expectations.
Help parents interpret behavioral cues from their infant to foster
healthy parentchild interaction. For example, help them recognize
when the infant is awake and alert, and point out to them that this
is a good time to provide stimulation.
Help parents identify ways they can promote the infants develop-
ment, such as providing stimulation by shaking a rattle in front of
the infant, talking to the infant in a gentle voice, and looking at the
infant when feeding him. This encourages practices that promote the
infants development. Sensory experiences promote cognitive devel-
opment.
Attend: Explore with parents ways to cope with stress caused by the
infants behavior to increase their coping skills.
Praise parents for their attempts to enhance their interaction with
the infant to provide positive reinforcement.
Manage: Provide parents with information on sources of support
and special infant services to encourage them to continue to foster
their infants development.
Attachment Promotion; Developmental Care; Environmental
Management: Attachment Process; Family Integrity Promotion:
Childbearing Family; Infant Care; Sleep Enhancement
Reference
Byers, J. F., et al. (2006, JanuaryFebruary). A quasi-experimental trial on
individualized, developmentally supportive family-centered care. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 105115.
INEFFECTIVE INFANT FEEDING PATTERN

DEFINITION
Impaired ability of an infant to suck or coordinate the suck/swallow
response resulting in inadequate oral nutrition for metabolic needs
Inability to coordinate sucking, swallowing, and breathing
Inability to initiate or sustain effective suck
RELATED FACTORS
Anatomic abnormality Oral hypersensitivity
Neurological delay or impair- Prematurity
ment Prolonged NPO status
Growth and development Roles/relationships
EXPECTED OUTCOMES
The neonate will
Not lose more than 10% of birth weight within first week of life.
Gain 47 oz (113.5198.5 g) after first week of life.
Remain hydrated.
Receive adequate supplemental nutrition until able to suckle suffi-
ciently.
Establish effective suck-and-swallow reflexes that allow for
adequate intake of nutrients.
The parents will
Identify factors that interfere with neonate establishing effective
feeding pattern.
Express increased confidence in their ability to perform appropri-
ate feeding techniques.
Breast-Feeding Establishment: Infant; Breast-Feeding Maintenance;
Muscle Function; Nutritional Status: Food & Fluid Intake;
Swallowing Status
Determine: Weigh neonate at the same time each day on the same
scale to detect excessive weight loss early.
Continuously assess neonates sucking pattern to monitor for inef-
fective patterns.
Assess parents knowledge of feeding techniques to help identify
and clear up misconceptions.
Assess parents level of anxiety about the neonates feeding diffi-
culty. Anxiety may interfere with the parents ability to learn new
techniques.
201
Monitor neonate for poor skin turgor, dry mucous membranes,
decreased or concentrated urine, and sunken fontanels and eyeballs
to detect possible dehydration and allow for immediate intervention.
Record the number of stools and amount of urine voided each
shift. An altered bowel elimination pattern may indicate decreased
food intake; decreased amounts of concentrated urine may indicate
dehydration.
Assess the need for gavage feeding. The neonate may temporarily
require alternative means of obtaining adequate fluids and calories.
If neonate requires intravenous nourishment, assess the insertion
site, amount infused, and infusion rate every hour to monitor fluid
intake and identify possible complications, such as infiltration and
phlebitis.
Perform: Remain with the parents and neonate during the feeding to
identify problem areas and direct interventions.
For bottle-feeding, record the amount ingested at each feeding; for
breast-feeding, record the number of minutes the neonate nurses at
each breast and the amount of any supplement ingested to monitor
for inadequate caloric and fluid intake.
Provide an alternative nipple, such as a preemie nipple. A preemie
nipple has a larger hole and softer texture, which makes it easier for
the neonate to obtain formula.
For breast-feeding, ensure that the neonates tongue is properly
positioned under the mothers nipple to promote adequate sucking.
Alternate oral and gavage feeding to conserve the neonates
energy.
Inform: Teach parents to place the neonate in the upright position
during feeding to prevent aspiration.
Teach parents to unwrap and position a sleepy neonate before
feeding to ensure that the neonate is awake and alert enough to
suckle sufficiently.
Attend: Provide positive reinforcement for the parents efforts to
improve their feeding technique to decrease anxiety and enhance
feelings of success.
Manage: Assess neonate for neurologic deficits or other pathophysio-
logic causes of ineffective sucking to identify the need for referral
for more extensive evaluation.
Attachment Promotion; Breast-Feeding Assistance; Lactation Coun-
seling; Nonnutritive Sucking
Reference
Kelly, M. M. (2006, SeptemberOctober). Primary care issues for the healthy
premature infant. Journal of Pediatric Health Care, 20(5), 293299.
RISK FOR INFECTION

DEFINITION
At risk for being invaded by pathogenic organisms
RISK FACTORS
Altered immune function Pharmaceutical agents
Amniotic membrane rupture Inadequate primary (such as
Chronic disease skin) or secondary (such as
Environmental exposure to inflammatory response)
pathogens defenses
Invasive procedures Malnutrition
Lack of knowledge about Tissue destruction
causes of infection Trauma
Fluid/electrolytes Risk management
EXPECTED OUTCOMES
The patient will
Have normal temperature, WBC count, and differential.
Maintain good personal and oral hygiene.
Have clear and odorless respiratory secretions.
Have normal urine and be free from evidence of diarrhea.
Exhibit wounds and incisions that show no signs of infection; and
intravenous sites with no signs of inflammation.
Take ___ ml of fluid and ___ g of protein daily.
Identify infection risk factors, and signs and symptoms of infection.
Immune Status; Infection Status; Knowledge: Treatment Procedure(s),
and Infection Control; Nutritional Status; Risk Control; Risk Detec-
tion; Wound Healing: Primary Intention, and Secondary Intention
Determine: Monitor and record temperature after surgery at least
every 4 hr; report elevations immediately as this may signal onset of
pulmonary complications, wound infection or dehiscence, UTI, or
thrombophlebitis
Monitor WBC count, as ordered. Report elevations or
depressions. Elevated total WBC count indicates infection. Markedly
decreased WBC count may indicate decreased production resulting
from extreme debilitation or severe lack of vitamins and amino
acids. Any damage to bone marrow may suppress WBC formation.
Monitor culture results of urine, respiratory secretions, wound
drainage, or blood according to facility policy and physicians order.
This identifies pathogens and guides antibiotic therapy.
Perform: Perform hand hygiene before and after providing care, and
direct patient to do this before and after meals and after using
203
bathroom, bedpan, or urinal to avoid spread of pathogens; also, use
strict sterile technique when handling would dressings to maintain
asepsis.
Offer frequent oral hygiene to prevent colonization of bacteria
and reduce risk of descending infection. Disease and malnutrition
may reduce moisture in mucous membranes of mouth and lips.
Change intravenous tubing and give site care every 2448 hr or as
facility policy dictates to help keep pathogens from entering body.
Rotate intravenous sites every 4872 hr or as facility policy dictates
to reduce chances of infection at individual sites.
Have patient cough and deep-breathe every 4 hr after surgery to
help remove secretions and prevent pulmonary complications. Pro-
vide tissues to encourage expectoration and convenient disposal bags
for expectorated sputum to reduce spread of infection.
Help patient turn every 2 hr. Provide skin care, particularly over
bony prominences to help prevent venous stasis and skin breakdown.
Assist patient when necessary to ensure that perianal area is clean
after elimination. Cleaning perineal area by wiping from the area of
least contamination (urinary meatus) to the area of most contamina-
tion (anus) helps prevent genitourinary infections.
Use sterile water for humidification or nebulization of oxygen.
This prevents drying and irritation of respiratory mucosa, impaired
ciliary action, and thickening of secretions within respiratory tract.
Inform: Instruct patient to immediately report loose stools or
diarrhea which may indicate need to discontinue or change
antibiotic therapy; or to test for Clostridium difficile.
Instruct patient about good hand hygiene, factors that increase infec-
tion risk, and signs and symptoms of infection to encourage patient
to participate in care and modify lifestyle to maintain optimum health.
Attend: Unless contraindicated, encourage fluid intake of
3,0004,000 ml daily to help thin mucus secretions; and offer high-
protein supplements to help stabilize weight, improve muscle tone
and mass, and aid wound healing.
Manage: Arrange for protective isolation if patient has compromised
immune system. Monitor flow and number of visitors. These meas-
ures protect patient from pathogens in environment.
Incision Site Care; Infection Protection; Teaching: Procedure/Treatment;
Wound Care
Reference
Marrs, J. A. (2006, April). Care of patients with neutropenia. Clinical Journal
of Oncology Nursing, 10(2), 164166.
RISK FOR INJURY

DEFINITION
At risk for injury as a result of environmental conditions interacting
with the individuals adaptive and defensive resources
RISK FACTORS
External Internal
Biological: Community immu- Abnormal blood profile:
nization level; microorganisms Altered clotting factors;
Chemical: Cosmetics; drugs, decreased hemoglobin; leuko-
pharmaceutical agents; dyes; cytosis/leucopenia; sickle cell;
alcohol, nicotine, preservatives; thalassemia; thrombocytopenia
poisons Biochemical dysfunction
Human: Nosocomial agents; Immune or autoimmune
staffing patterns; cognitive, disorder
affective, psychomotor factors Developmental age: physiologi-
Nutritional: Food types, cal and/or psychosocial
vitamins Tissue hypoxia
Physical: Design, structure, and
arrangement of community,
building, and/or equipment
Mode of transport
Behavior Knowledge
Emotional Risk management
EXPECTED OUTCOMES
The patient will
Acknowledge presence of environmental hazards in their everyday
surroundings.
Take safety precautions in and out of home.
Instruct children in safety habits.
Childproof house to ensure safety of young children and
cognitively impaired adults.
Immune Status; Risk Control; Safety Behavior: Home Physical Envi-
ronment; Safety Behavior: Personal; Safety Status: Falls Occurrence;
Safety Status: Physical Injury
Determine: Help patient identify situations and hazards that can
cause accidents to increase patients awareness of potential dangers.
Perform: Arrange environment of patient with dementia to minimize
risk of injury:
Place furniture against walls.
Avoid use of throw rugs.
205
Maintain lighting so that patient can find her way around room
and to bathroom. Poor lighting is a major cause of falls.
Prevent iatrogenic harm to hospitalized patient by following the
2007 National Patient Safety goals. This resource provides compre-
hensive measures designed to prevent harm.
Follow agency policy regarding the use of restraintsthey are
generally used as a last resort after other measures have failed.
Agency policies will provide clear direction to use restraints safely.
Inform: Encourage adult patient to discuss safety rules with children
to foster household safety. For example:
Dont play with matches.
Use electrical equipment carefully.
Know location of the fire escape route.
Dont speak to strangers.
Dial 911 in an emergency.
Attend: Encourage patient to make repairs and remove potential
safety hazards from environment to decrease possibility of injury.
Manage: Refer patient to appropriate community resources for more
information about identifying and removing safety hazards. This
enables patient and family to alter environment to achieve optimal
safety level.
Environmental Management: Safety; Fall Prevention; Health Educa-
tion; Parent Education: Adolescent; Parent Education: Childrearing
Family; Risk Identification; Surveillance: Safety
References
Bright, L. (2005, January). Strategies to improve the patient safety outcome
indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1),
2936.
Yuan, J. R., & Kelly, J. (2006, February). Falls prevention, or I think I can, I
think I can: An ensemble approach to falls management. Home Healthcare
Nurse, 24(2), 103111.
RISK FOR PERIOPERATIVE-POSITIONING

INJURY
DEFINITION
At risk for inadvertent anatomical and physical changes as a result
of posture on equipment used during an invasive/surgical procedure
RISK FACTORS
Disorientation Muscle weakness
Edema Obesity
Emaciation Sensoryperceptual
Immobilization disturbances from anesthesia
Activity/exercise Physical regulation
Fluid/electrolytes Risk management
Pharmacological function
EXPECTED OUTCOMES
The patient will
Maintain effective breathing patterns.
Maintain adequate cardiac output.
Have surgical positioning that facilitates gas exchange.
Not show evidence of neurologic, musculoskeletal, or vascular
compromise.
Maintain tissue integrity.
Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-
logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue
Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral
Determine: Document and report the results of the preoperative
nursing assessment. Identify factors predisposing patient to tissue
injury. This information guides interventions.
Perform: Use the appropriate mode of patient transportation
(stretcher, patient bed, wheelchair, or crib) to ensure patient safety.
Make sure an adequate number of staff members assist with
transferring patientobtain at least two for moving patient onto an
operating room bed and at least four for moving anesthetized
patient off operating room bed. Adequate staffing enhances safety.
Check the operating room bed before surgery for proper function-
ing. Intraoperative bed malfunction can result in increased anesthe-
sia time and a more difficult surgical approach.
Ensure proper positioning (follow institutional policies):
Check patients neck and spine for proper alignment to avoid
trauma.
Check that patients legs are straight and ankles uncrossed.
Crossed ankles cause pressure on tissue, vessels, and nerves.
207
Place a safety strap 29 (5 cm) above patients knees, tight
enough to restrain without compromising superficial venous
return. Applied too tightly, the safety strap may cause venous
thrombosis or compression of tibial, peroneal, or sciatic nerves.
Secure patients arms at his sides with a draw sheet, with palms
down, making sure that no part of the arm or hand extends
over the mattress. Hyperextension can cause injury to the
brachial plexus. Supination of palms minimizes pressure.
Apply eye pads if patients eyelids dont remain closed or if
surgery is being performed on his head, neck, or chest. If allowed to
remain open, the eyes may dry out and become infected. Corneal
abrasions may result from drapes and other foreign material rubbing
against the eyes.
If surgery is expected to last more than 2 hr or if patient is pre-
disposed to a pressure injury, place padding under his occiput,
scapulae, olecranon, sacrum, coccyx, and calcaneus to protect poten-
tial pressure points. Apply a padded footboard to support patients
feet. Avoid plantarflexion, and prevent stretching of the tibial nerve
and subsequent foot drop.
Assess patient position following each positional change to ensure
proper body alignment and adequate padding and support.
Inform: Tell patient about positioning measures planned to reduce
preoperative anxiety.
Attend: Assure patient that careful positioning of the body will be
carried to reduce worry about possible injury.
Manage: Consult with a physical or occupational therapist if special
protective equipment is needed to ensure safety for the patient.
Circulatory Care: Mechanical Assist Device, Circulatory
Precautions; Infection Control: Intraoperative; Positioning: Intraoper-
ative; Skin Surveillance; Surgical Precautions; Temperature
Regulation: Intraoperative
Reference
Millsaps, C. C. (2006, January). Pay attention to patient positioning! RN,
69(1), 5963.
INSOMNIA
DEFINITION
A disruption in the amount and quality of sleep that impairs func-
tioning
Observed changes in affect Reports difficulty falling asleep
Observed lack of energy, diffi- and staying asleep
culty concentrating Reports dissatisfaction with
Increased work or school sleep
absenteeism Reports early morning awak-
Reports changes in mood ening
Reports decreased health status, Reports nonrestorative sleep
quality of life
RELATED FACTORS
Activity pattern Grief
Anxiety Inadequate sleep hygiene
Depression Intake of stimulants
Environmental factors Intake of alcohol
Fear Medication
Gender-related hormonal shifts Physical discomfort
Coping Sleep/rest
Emotional Values/beliefs
EXPECTED OUTCOMES
The patient will
Identify factors that prevent or promote sleep.
Achieve sleep for ___ hours without interruption.
Report feeling well-rested.
Be free from signs of sleep deprivation.
Alter diet and habits to promote sleep, such as reducing caffeine
and alcohol intake before bedtime.
Not exhibit sleep-related behavioral symptoms, such as
restlessness, irritability, lethargy, and disorientation.
Perform relaxation exercises at bedtime.
Anxiety Level; Fear Level; Mood Equilibrium; Personal Well-Being;
Rest
Determine: Assess patients daytime activity and work patterns;
travel history; normal bedtime; problems associated with sleep; qual-
ity of sleep; sleeping environment; personal beliefs about sleep; use
of alcohol, caffeine, hypnotics, and nicotine. Assessment information
will assist in selecting appropriate interventions.
209
Perform: Ask patient to help make changes in the environment that
would promote sleep. This allows patient to have an active role in
treatment.
Administer medications on a schedule that will allow for
maximum rest. Disturbing for medication administration during rest
periods will disrupt sleep patterns. If the patient requires diuretics
in the evening, give far enough in advance to allow peak effect
before bedtime. Other medications that may interfere with sleep are
-blockers, MAO inhibitors, and phenytoin.
Provide patient with sleep aids, such as pillows, bath before sleep,
food or drink, and reading materials to promote ease in falling
asleep. Milk and some high-protein snacks, such as cheese and nuts,
contain L-tryptophan, a sleep promoter. Personal hygiene and
prebedtime rituals promote sleep in some patients.
Develop a sleep log with the patient describing sleep disturbances
and the effect on daytime functioning. The log will help both
patient and nurse to evaluate progress in evaluating sleep patterns.
deep breathing, meditation, aromatherapy, and progressive muscle
relaxation. Practice with the patient at bedtime. Purposeful
relaxation efforts usually help promote sleep.
Instruct patient to eliminate or reduce caffeine and alcohol intake
and avoid foods that interfere with sleep (e.g., spicy foods). Foods
and beverages containing caffeine consumed fewer than 4 hr before
bedtime may interfere with sleep. Alcohol disrupts normal sleep,
especially when ingested immediately before retiring.
When anxiety is a factor in sleep deprivation, teach coping tech-
niques to reduce the frustration of being unable to sleep.
Attend: Listen to the patients description of insomnia. Allow time for
the patient to talk about his frustration. Being able to have a sensitive
listener may help reduce some of the frustration and may lead to new
ideas about how to help the patient resolve his sleep issues.
Ask the patient each day to describe the quality of his sleep. Patients
are sometimes unaware of the periods in which they do sleep.
Manage: Refer to case manager/social worker to ensure that follow-
up is provided.
Biofeedback; Calming Techniques; Coping Enhancement; Energy
Management; Security Enhancement; Simple Relaxation Therapy;
Sleep Enhancement
Reference
Holcomb, S. S. (2006, February). Recommendations for assessing insomnia.
The Nurse Practitioner, 3(2), 5560.
DECREASED INTRACRANIAL
ADAPTIVE CAPACITY
DEFINITION
Intracranial fluid dynamic mechanisms that normally compensate for
increases in intracranial volumes are compromised, resulting in
repeated disproportionate increases in intracranial pressure (ICP) in
response to a variety of noxious and nonnoxious stimuli
Baseline ICP 10 mm Hg
Disproportionate increase in ICP following single nursing
maneuver
Elevated P2 ICP wave form
Repeated increase of 10 mm Hg for more than 5 min following
external stimuli
Volume pressure response test variation (volumepressure ratio
greater than 2, pressurevolume index 10)
Wide amplitude ICP waveform
RELATED FACTORS
Brain injuries Sustained hypotension with
Decreased cerebral perfusion intracranial hypertension
Sustained increased ICP
Cardiac functioning Neurocognition
Comfort Pharmacologic function
Elimination Respiratory functioning
Fluid and electrolytes Values/beliefs
EXPECTED OUTCOMES
The patient will
Maintain effective breathing pattern and normal ABG levels.
Show no evidence of fever.
Modify environment to eliminate noxious stimuli.
Maintain regular bowel function.
Maintain skin integrity.
Remain free of signs and symptoms of infection.
Not show evidence of neurological compromise.
Electrolyte & AcidBase Balance; Fluid Balance; Neurological Status:
Consciousness; Wound Healing: Primary Intention
Determine: Assess vital signs, temperature, pulses, heart sounds,
jugular vein distension; electrocardiogram, history of hypertension;
mental status, reflexes, response to pain, papillary size and response
to light; respiratory rate, depth, and pattern of respiration, ABG,
pulse oximetry; monitor ICP wave forms for trends over time. Mon-
itor for damped waves. Assess cerebral perfusion pressure.
211
Assessment information will assist in identifying appropriate
interventions.
Perform: Maintain ICP monitoring systems if used. Careful attention
must be paid to ensure that the system is functioning to provide
accurate information. Use sterile technique for dressing changes to
prevent contamination of equipment and infection.
Maintain a patent airway and suction only if needed. Suctioning
stimulates coughing and Valsalva maneuver; Valsalva increases
intrathoracic pressure, decreases cerebral venous drainage, and
increases cerebral blood volume, resulting in increased ICP. Elevate
head of the bed 1530 or as ordered, and use sandbags, rolled
towels, or small pillows to keep head in a neutral position. Reposi-
tion patient by using a draw sheet to prevent atrophy. Use minimal
amount of stimuli when caring for the patient. Turn and reposition
patient every 2 hr to prevent atelectasis.
Perform ROM exercises to maintain muscle tone.
Inform: Teach patient and family those aspects of care in which they
can participate without feeling anxious. Instruct family members in
gentle stroking of patients face, arms, or hand. Touch by family
members may lower the ICP in some cases.
Attend: Provide nursing care in a calm, reassuring manner. Avoid
discussion of upsetting topics near the bedside. This helps prevent
emotional upset that can increase ICP. Encourage patient and family
to express feelings associated with diagnosis, treatment, and recov-
ery. Expression of feelings helps patient and family cope with treat-
ment.
Manage: Arrange for frequent multidisciplinary/family care
conference in order to keep care goal-oriented. Refer patient and
family to support group to help deal with the injury, diagnosis, or
recovery. Refer to social worker/case manager for follow-up care,
home assessment, home visits, and referral to community agencies.
AcidBase Management; Bedside Laboratory Testing; Cerebral
Edema Management; FluidElectrolyte Management; ICP Monitoring
Reference
Littlejohns, L., & Bader, M. K. (2005, OctoberDecember). Prevention of sec-
ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),
501514.
NEONATAL JAUNDICE
DEFINITION
The yellow orange tint of the neonates skin and mucous membranes
that occurs after 24 hours of life as a result of unconjugated biliru-
bin in the circulation
Neonate age 17 days
Yellow orange skin
Yellow sclerae
Yellow mucous membranes
Abnormal blood profile (hemolysis; total serum bilirubin 2 mg/dl;
total serum bilirubin in high-risk range on age in hour-specific
nomogram)
RELATED FACTORS
Abnormal weight loss (7% 8% in breast-feeding newborn)
Feeding pattern not well established
Infant experiences difficulty making transition to extrauterine
life
Stool (meconium) passage delayed
Elimination Growth and development
EXPECTED OUTCOMES
The neonate will
Establish effective feeding pattern (breast or bottle) that enhances
stooling.
Not experience injury as a result of increasing bilirubin levels.
Receive bilirubin assessment and screening within the first week of
life to detect increasing levels of serum bilirubin.
Receive appropriate therapy to enhance bilirubin excretion.
Receive nursing assessments to determine the risk for severity of
jaundice.
Bowel Elimination; Breast-Feeding Establishment: Infant; Nutritional
Status; Risk Control; Risk Detection
Determine: Evaluate maternal and delivery history for risk factors
for neonatal jaundice (Rh, ABO, G6PD deficiency, direct Coombs,
prolonged labor, maternal viral illness, medications) to anticipate
which neonates are at higher risk for jaundice.
Perform: Collect and evaluate laboratory blood specimens as ordered
or per unit protocol to permit accurate and timely diagnosis and
treatment of neonatal jaundice.
213
Inform: Educate parents regarding newborn care at home in relation
to appearance of jaundice in association with any of the following:
no stool in 48 hr, lethargy with refusal to nurse or bottle feed, less
than 1 wet diaper in 12 hr, abnormal infant behavior. Parent educa-
tion is crucial for the time after the neonate is discharged. Parents
are the major decision makers concerning whether and when to
bring the neonate back for medical and nursing assessments after
being discharged from the hospital.
Attend: Provide caring support to the family if a breast-fed neonate
must receive supplementation. It can be upsetting and result in feel-
ings of inadequacy to a breast-feeding mother for her neonate to
require supplementation.
Manage: Coordinate care and facilitate communication between fam-
ily, nursing staff, pediatrician, and lactation specialist. A multidisci-
plinary approach that includes the family enhances communication
and improves outcomes.
Attachment Promotion; Bottle Feeding; Bowel Management; Breast-
Feeding Assistance; Capillary Blood Sample; Discharge Planning;
Infant Care; Kangaroo Care; Newborn Monitoring; Nutritional
Monitoring; Risk Identification: Childbearing Family; Surveillance;
Teaching: Infant Nutrition; Vital Signs Monitoring
Reference
Bhutani, V. K., Johnson, L. H., Schwoebel, A., & Gennaro, S. (2006). A sys-
tems approach for neonatal hyperbilirubinemia in term and near-term new-
borns. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35,
444455.
DEFICIENT KNOWLEDGE (SPECIFY)

DEFINITION
Absence or deficiency of cognitive information related to a specific
topic
Inability to follow through with directions
Inability to perform well on a test
Inappropriate or exaggerated behaviors (hysteria, hostility,
agitation, apathy)
Verbalization of the problem
RELATED FACTORS
Cognitive limitation Lack of recall
Information misinterpretation Unfamiliarity with information
Lack of exposure resources
Lack of interest in learning
Activity Nutrition
Communication Sleep
Knowledge
EXPECTED OUTCOMES
The patient will
Communicate desire to understand disease state and need for
treatment.
Demonstrate ability to perform new health-related procedures.
Set realistic learning goals within target dates.
State intention to make needed modifications in lifestyle.
Cognition; Concentration; Information Processing; Knowledge: Dis-
ease Process; Knowledge; Health Behaviors; Knowledge: Health
Resources; Knowledge: Illness Care; Stress Level
Determine: Determine level of knowledge and skills patient already
possesses about his or her health status; motivation to understand
what is needed to improve health status; obstacles to learning; sup-
port systems; usual coping patterns; beliefs about health and treat-
ment of disease; ethnicity; financial resources. Assessment informa-
tion will assist in identifying appropriate interventions.
Perform: Establish an environment of mutual trust and respect to
enhance learning. Consistency between action and words, combined
with the patients self-awareness ability to share this awareness with
others, and receptiveness to new experiences form the basis of a
trusting relationship.
215
Develop with patient specific learning goals with target dates.
Involving patient in planning meaningful goals encourages
compliance.
Select teaching strategies that will enhance teaching/learning effec-
tiveness, such as discussion, demonstration, role-playing, and visual
materials. Provide all the equipment needed for the patient to learn.
This reduces frustration, aids learning, and minimizes dependence by
promoting self-care.
Inform: Teach those skills that the patient must incorporate into
daily living. Have patient do return demonstration of each skill to
aid in gaining confidence.
When teaching, go slowly and repeat frequently. Offer small
amounts of information and present it in various ways. By building
cognition, patient will be better able to complete self-care measures.
Include family members.
Demonstrate to family members how each self-care measure is
broken down into simple tasks to enhance patients success and fos-
ter a sense of control.
Attend: Encourage family members to participate in and have
patience toward learning process (patient may need to repeat new
skills multiple times) to help create a therapeutic environment after
discharge.
Manage: Have patient incorporate learned skills into care while still
in the hospital. This allows practice and time for feedback.
Provide patient and/or family with names and telephone numbers
of resource people or community agencies so that care is continuous
and follow-up is possible after discharge.
If financial hardship interferes with the ability of the family to
provide equipment and supplies, offer a referral to a social worker
to improve the familys access to financial assistance.
Behavior Management; Behavior Modification; Decision-Making
Support; Energy Management; Family Support; Financial Resource
Assistance; Health Education; Healthcare Information Exchange:
Risk Identification; Learning Facilitation; Support System Enhance-
ment; Teaching Procedure/Treatment
Reference
Shen, Q., et al. (2006, MayJune). Evaluation of a medication education pro-
gram for elderly hospitalized inpatients. Geriatric Nursing, 27(3), 184192.
READINESS FOR ENHANCED KNOWLEDGE

DEFINITION
The presence or acquisition of cognitive information related to a
specific topic that is sufficient for meeting health-related goals and
can be strengthened
Expresses an interest in Behaves congruent with
learning expressed knowledge
Explains knowledge of Describes previous experience
topic related to other topics
Communication Risk management
Knowledge Values and beliefs
EXPECTED OUTCOMES
The patient will
Identify new sources for enhancing knowledge in the topic of
interest.
Make use of all relevant resources to enhance knowledge.
Ask questions where new information needs clarification.
Begin practicing new behaviors gleaned from enhanced knowledge.
Knowledge: Health Promotion
Determine: Assess current health status; problems, restrictions, limita-
tions; personal habits, such as the use of tobacco, drugs, alcohol con-
sumption, level of knowledge about disease process; communication
skills (verbal and written), degree of motivation to maintain health;
familiarity with technology as a source of learning. Assessment infor-
mation will help identify appropriate interventions.
Perform: Plan a health maintenance program for the patient and
family members addressing current problems. Developing a plan
with the family will increase the probability of compliance by giving
them information to review each day. Provide the family and patient
with a written copy. A written copy can be posted in the patients
home where it is always available for review.
Inform: Provide books and videos that will help the patients quest
for enhanced knowledge. Supplying some materials directly may be
a motivation for the patient to search further.
Direct patient and family to use other sources such as libraries,
the Internet, or professional organizations. An independent search
results in the patient developing confidence in his or her ability to
go much deeper into the area of interest.
217
cerns related to the knowledge and skills that patient needs. This
promotes greater ease in managing challenging situations.
Demonstrate willingness to repeat instruction and demonstrations
of skills needed by the patient. Repetition will reinforce learning and
give the patient added confidence in his or her ability to comply.
Be available to answer questions and correct misconceptions for
the patient/family to enhance the effectiveness of learning.
Introduce the patient and/or family to individuals who may have
had experience with the health problems in question if that is advis-
able. In many cases, having the opportunity to talk to another per-
son that has coped well with the same problem will provide support
and encouragement to the patient.
Manage: Refer to social worker/case manager early in the patients
hospitalization. This person will begin identifying the types of sup-
port and resources the family and patient will need to prepare for
follow on care.
Refer to social and community resources, such a stroke support
group, and Alzheimers family support group, American Cancer
Society. The patient can contact these sources for additional
information as needed.
Discharge Planning; Individual; Learning Enhancement; Learning
Facilitation; Referral; Teaching
Reference
Eldh, A. C., et al. (2006, September). Conditions for patient participation and
non-participation in health care. Nursing Ethics, 13(5), 503514.
SEDENTARY LIFESTYLE
DEFINITION
Reports a habit of life that is characterized by a low physical activ-
ity level
Chooses a daily routine lacking physical exercise
Demonstrates physical deconditioning
Verbalizes preference for activities low in physical activity
RISK FACTORS
Deficient knowledge of health benefits of physical exercise
Lack of interest, motivation, resources, and/or training
Activity/exercise Nutrition
Growth and development Risk management
Knowledge
EXPECTED OUTCOMES
The patient will
Maintain independent living status with reduced risk for falling.
Identify barriers to increasing physical activity level.
Identify health benefits to increasing physical activity level.
Increase physical activity and limit inactive forms of diversion,
such as television and computer games.
Seek professional consultation to develop an appropriate plan to
increase physical activity.
Identify factors that enhance readiness for sleep.
Demonstrate readiness for enhanced sleep through the use of
appropriate sleep hygiene measures.
Have amount of sleep congruent with developmental needs and
experience rapid-eye-movement (REM) sleep.
Express a feeling of being rested after sleep.
Increase lean muscle and bone strength and decrease body fat.
Demonstrate weight control and, if appropriate, weight loss.
Exhibit enhanced psychological well-being and reduced risk of
depression.
Have reduced depression and anxiety and an improved mood.
Demonstrate increased ability to perform activities of daily living
within limits of chronic, disabling conditions.
Activity Intolerance; Endurance; Energy Conservation; Health-
Promoting Behavior; Immobility Consequences: Physiologic
Determine: Identify barriers and enhancers to increasing physical
activity, including time management, diet, lifestyle, access to
219
facilities, and safe environments in which to be active. Breaking
down barriers and building opportunities for activity increase the
probability of consistent physical activity.
Perform: Develop a behavior modification plan based on patients
condition, history, and precipitating factors to maximize physical
activity and compliance.
Inform: Instruct patient to keep a daily activity and dietary log to
help him or her achieve a more objective view of his or her behav-
ior.
Educate patient about how sedentary lifestyle affects cardiovascu-
lar risk factors (such as hypertension, dyslipidemia,
hyperinsulinemia, insulin resistance) to motivate patient to be more
active.
Teach exercises for increasing strength and endurance to maintain
mobility and prevent musculoskeletal degeneration.
Educate patient about using the bedroom only for sleep or sexual
activity and avoiding other activities such as watching television,
reading, and eating to increase sleep efficiency.
Attend: Provide counseling tailored to patients risk factors, needs,
preferences, and abilities to enhance emotional well-being and moti-
vation for physical activity.
Discuss the need for activity that will improve psychosocial well-
being to encourage compliance with activities.
Discuss behavioral risk factors in lack of motivation such as
ingestion of carbohydrates, caffeine, nicotine, alcohol, sedatives, hyp-
notics, and fluid intake, to focus behavior on positive outcomes of
increased physical activity.
Manage: Provide education about community resources available to
increase physical activity to decrease barriers to activity.
Activity Therapy; Energy Management; Teaching: Prescribed Activity/
Exercise
Reference
Zabinski, M. F., et al. (2007, January). Patterns of sedentary behavior among
adolescents. Health Psychology, 26(1), 113120.
RISK FOR IMPAIRED LIVER FUNCTION

DEFINITION
At risk for liver dysfunction
RISK FACTORS
Hepatotoxic medications (e.g., Viral infection (e.g., hepatitis
acetaminophen, statins) A, B, or C, Epstein-Barr)
HIV coinfection Chronic biliary obstruction
Substance abuse (e.g., alcohol, and infection
cocaine) Nutritional deficiencies
Risk management
Fluids/electrolytes
EXPECTED OUTCOMES
The patient will
State effects of environmental and ingested chemicals and
substances on their health and liver function.
Work with industry managers and with public health officials to
lower or eliminate the presence of environmental chemicals and
substances in their work or living environment.
Have liver function indicators within normal limits.
Modify lifestyle and risk behaviors to avoid behaviors leading to
hepatic dysfunction and inflammation.
Maintain long-term follow-up for chronic illness with healthcare
provider.
Manage concurrent disease processes that impact hepatic function.
Optimize nutritional intake for needs.
Acknowledge the impact of medications on hepatic function.
Observe measures to avoid the spread of infection to self and to
others.
Health-Promoting Behavior; Risk ControlAlcohol; Risk Control
Drug Use; Safe Home Environment; Substance Addiction
Consequences
Determine: Assist patient and family to assess workplace and home
environments for potential hepatotoxic substances to increase
patients awareness of hazards in the environment and to lower
potential for hepatic injury.
Monitor for clinical manifestations of hepatic inflammation and
dysfunction to notify physician in order to initiate treatment if liver
function is compromised. Clinical manifestations may include
fatigue, depression or mood changes, anorexia, RUQ tenderness,
pruritis, jaundice, bruising, or nontraumatic bleeding.
221
Monitor customary clinical laboratory tests to alert the healthcare
provider of the status of the immune/inflammatory response, the
degree of hepatic metabolic dysfunction, and the impact of concur-
rent disorders on liver function. Clinical laboratory tests include
complete blood cell (CBC) count: lower red blood cell count,
elevated WBC (increased immunocyte and inflammatory responses);
basic metabolic panelaltered electrolyte balance, elevated glucose,
elevated blood urea nitrogen and creatinine level, elevated HbA1c;
hepatic plasma markers: elevated liver enzymes (alanine aminotrans-
ferase, aspartate aminotransferase, and -glutamyltranspeptidase);
positive immunoassays for pathogen and viral antigens; elevated
ammonia; elevated bilirubin; low coagulation factors; low total
protein/albumin; elevated lipid panel.
Perform: Carry out postprocedure measures, as ordered, to identify
and/or minimize complications.
Inform: Teach patient about the following: perform hand hygiene
before and after personal hygiene and care; cover draining and non-
healing wounds; report to care provider; inform others of infectious
condition so that each observes barrier precautions; adhere to
prescribed plan of care and treatment with immune system modifiers
(antibiotics, antivirals, interferon, others); maintain a balanced nutri-
tional diet intake. These measures minimize patients risk for self-
infection and spread of infection and allow the patient to help modify
lifestyle to maintain optimum health level for self and for others.
Along with healthcare team, prepare the patient for and later evaluate
the results of liver biopsy and provide explanation to patient and family.
The patient and family need understanding of purpose for and
implications of results obtained from a liver biopsy. This support and
education helps the patient understand rationale for plan of treatment
and genetic counseling for genetically linked hepatic disorders.
Attend: Provide a nonjudgmental attitude toward patients lifestyle
choices to promote feelings of self-worth.
Manage: Refer patient to counseling and therapy to address lifestyle
choices and risk behaviors. Modification of behaviors will provide
risk avoidance for drug and alcohol abuse and exposure to body-
substance pathogen infection.
Behavioral Modification; Environment Risk Protection; Infection
Protection; Risk Identification; Risk IdentificationGenetic; Self-
Modification Assistance; Sports Injury Prevention; Surveillance
Reference
McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis
for disease in adults and children (5th ed., pp. 14131428). St. Louis, MO:
Elsevier-Mosby.
RISK FOR LONELINESS

DEFINITION
At risk for experiencing discomfort associated with a desire or need
for more contact with others
RISK FACTORS
Affectional deprivation Physical isolation
Cathectic deprivation Social isolation
EXPECTED OUTCOMES
The patient will
Identify feelings of loneliness and express desire to socialize more.
Identify behaviors that lead to loneliness.
Identify people who will likely support and accept him.
Spend time with others.
Be comfortable in social settings, interact with peers, and receive
support from others.
Make specific plans to continue involvement with others, such as
through recreational activities or social interaction groups.
Loneliness Severity; Risk Control; Social Involvement; Social Support
Determine: Work with patient to identify factors and behaviors that
have contributed to loneliness to begin changing behaviors that may
have alienated others.
Help patient identify feelings associated with loneliness. This lessens
the impact of feelings and mobilizes energy to counteract them.
Perform: Spend sufficient time with patient to allow him to express
his feelings of loneliness to establish trusting relationship.
Work with patient to establish goals for reducing feelings of lone-
liness after he leaves healthcare setting to focus energy on specific
objectives.
Inform: Inform patient that assistance is available to help him
express feelings of loneliness and identify ways to increase social
activity to bring issue into open and help patient understand that
you want to help him.
Help patient curb feelings of loneliness by encouraging one-on-one
interaction with others who are likely to accept him (e.g., church
members or patients with similar health problems) to promote feelings
of acceptance and support.
Help patient identify social activities he can initiate, such as
becoming active in a support group or volunteer organization. This
fosters feelings of control and increase social contacts.
223
Help patient accept that other people may view him differently
because of his illness, and explore ways of coping with their reactions
to help patient learn to cope with stigma associated with illness.
Attend: Encourage patient to address his needs assertively. By being
assertive, patient assumes responsibility for meeting his needs with-
out anger or guilt.
As patients comfort level improves, encourage him to attend
group activities and social functions to promote the use of social
skills.
Manage: Refer patient and family to social service agencies, mental
health center, and appropriate support groups to ensure continued
care and maintain social involvement.
Emotional Support; Socialization Enhancement; Spiritual Support;
Visitation Facilitation; Family Integrity Promotion
Reference
Perese, E. F., & Wolf, M. (2005, July). Combating loneliness among persons
with severe mental illness: Social network interventions characteristics,
effectiveness, and applicability. Issues in Mental Health Nursing, 6(6),
591609.
IMPAIRED MEMORY
DEFINITION
Inability to remember or recall bits of information or behavioral
skills
Inability to determine whether a behavior was performed
Inability to learn new skills or information or to perform
previously learned skills
Inability to recall factual information and recent or past events
Incidences of forgetting, including forgetting to perform a behavior
at a scheduled time
RELATED FACTORS
Anemia Fluid and electrolyte
Decreased cardiac output imbalance
Excessive environmental Hypoxia
disturbances Neurological disturbances
Emotional Self-care
Fluids and electrolytes
EXPECTED OUTCOMES
Express feelings about memory impairment.
Acknowledge need to take measures to cope with memory
impairment.
Identify coping skills to deal with memory impairment.
State specific plans to modify lifestyle.
Establish realistic goals to deal with further memory loss.
Cognition; Cognitive Orientation; Concentration; Memory; Neuro-
logical Status: Consciousness
Determine: Observe patients thought processes during every shift.
Document and report any changes. Changes may indicate progressive
improvement or a decline in patients underlying condition.
Perform: Implement appropriate safety measures to protect patient
from injury. He or she may be unable to provide for his or her own
safety needs.
Call patient by name and tell him or her your name. Provide
background information (place, time, and date) frequently through-
out the day to provide reality orientation. Use a reality orientation
board to visually reinforce reality orientation.
Spend sufficient time with patient to allow her to become comfort-
able discussing memory loss and establish a trusting relationship.
225
Be clear, concise, and direct in establishing goals to promote max-
imal use of patients remaining cognitive skills. Offer short, simple
explanations to patient each time you carry out any medical or
nursing procedure to avoid confusion.
Label patients personal possessions and photos, keeping them in
the same place as much as possible, to reduce confusion and create
a secure environment.
Inform: Inform patient that you are aware of his or her memory loss
and that you will help him or her cope with his or her condition to
bring the issue into the open and help patient understand that your
goal is to help him or her.
Teach patient ways to cope with memory loss (e.g., using a beeper
to remind her when to eat or take medications; using a pillbox
organized by days of the week; keeping lists in notebooks or a
pocket calendar; having family members or friends remind her of
important tasks). Reminders help limit the amount of information
patient must maintain in her memory.
Help patient and family members establish goals for coping with
memory loss. Discuss with family members the need to maintain the
least restrictive environment possible. Instruct them on how to main-
tain a safe home environment for patient. This helps ensure that
patients needs are met and promotes his or her independence.
Demonstrate reorientation techniques to family members and pro-
vide time for supervised return demonstrations to prepare them to
cope with patient with memory impairment.
Attend: Encourage patient to develop a consistent routine for
performing activities of daily living to enhance his self-esteem and
increase his self-awareness and awareness of his environment.
Encourage patient to interact with others to increase social
involvement, which may decline with memory loss.
Encourage patient to express the feelings associated with impaired
memory to reduce the impact of memory impairment on patients
self-image and lessen anxiety.
Manage: Help family members identify appropriate community sup-
port groups, mental health services, and social service agencies to
assist in coping with the effects of patients illness or injury.
Anxiety Reduction; Calming Technique; Cerebral Perfusion Promo-
tion; Dementia Management; Fluid and Electrolyte Management;
Memory Training; Neurologic Monitoring; Reality Orientation
Reference
Parahoo, K., et al. (2006, June). Expert nurses use of implicit memory in the
care of patients with Alzheimers disease. Journal of Advanced Nursing,
54(5), 563571.
IMPAIRED BED MOBILITY

DEFINITION
Limitation of independent movement from one bed position to another
Impaired ability to perform the following actions while in bed:
Move from supine to long sitting or long sitting to supine
Move from supine to prone or prone to supine
Move from supine to sitting or sitting to supine
Scoot or reposition body
Turn from side to side
RELATED FACTORS
Cognitive impairment Musculoskeletal and/or
Deconditioning neuromuscular impairment
Deficient knowledge Obesity
Environmental constraints Pain
Insufficient muscle strength Sedating medications
Activity/exercise
Physical regulation
EXPECTED OUTCOMES
The patient will
Have no complications associated with impaired bed mobility,
such as altered skin integrity, contractures, venous stasis, thrombus
formation, depression, altered health maintenance, and falls.
Maintain or improve muscle strength and joint ROM.
Achieve the highest level of bed mobility possible (independence,
independence with device, verbalization of needs for assistance with
bed mobility, requires assistance of one person or two people).
Demonstrate ability to use equipment or devices to assist with
moving about in bed safely.
Adapt to alteration in ability to move about in bed.
Participate in social, physical, and occupational activities to the
extent possible.
Body Positioning: Self-Initiated; Cognition; Immobility
Consequences: Physiological; Immobility Consequences: Psychocogni-
tive; Joint Movement, Mobility; Neurological Status: Consciousness
Determine: Identify patients level of independence using functional
mobility scale and document findings to provide continuity of care.
Monitor and record daily evidence of complications related to
impaired bed mobility (contractures, venous stasis, skin breakdown,
227
thrombus formation, depression, altered health maintenance or self-
care skills, falls). Assess patients skin every 2 hr to maintain skin
integrity.
Perform: Perform ROM exercises to affected joints, unless
contraindicated, at least once per shift. Progress from passive to
active ROM, as tolerated, to prevent joint contractures and muscle
atrophy.
Assist patient in maintaining anatomically correct and functional
body positioning to relieve pressure, thereby preventing skin break-
down and fluid accumulation in dependent extremities. Encourage
repositioning every 2 hr while in bed.
Establish a turning schedule for immobile patient. Encourage pro-
gressive mobility within patients limits to maintain muscle tone,
prevent complications, and promote self-care.
If you are uncertain about your ability to move the patient,
request help from colleagues to maintain safety.
Inform: Instruct patient and family members in techniques to
improve bed mobility and ways to prevent complications to help
prepare the patient and family members for discharge.
Demonstrate patients bed mobility regimen and note the date.
Have patient and family members perform a return demonstration
to ensure continuity of care and use of proper technique.
Attend: Encourage patient to participate in physical and
occupational therapy sessions. Incorporate equipment, devices, and
techniques used by therapists into your care. Request written
instructions from the patients therapists to use as a reference to
help ensure continuity of care and reinforce learned skills.
Manage: Refer patient to a physical therapist to continue improve-
ment in bed mobility and rehabilitate musculoskeletal deficits; and
an occupational therapist to continue to maximize self-care skills.
Assist patient in identifying and contacting resources for social
and spiritual support to promote the patients reintegration into the
community and help him maintain psychosocial health.
Bed Rest Care; Body Mechanics Promotion; Exercise Promotion:
Strength Training; Exercise Therapy: Joint Mobility; Exercise Ther-
apy: Muscle Control; Positioning
Reference
Lyder, C. H. (2006, August). Assessing risk and preventing pressure ulcers in
patients with cancer. Seminars in Oncology Nursing, 22(3), 178184.
IMPAIRED PHYSICAL MOBILITY

DEFINITION
Limitation in independent, purposeful physical movement of the
body or of one or more extremities
Gait changes, postural instability; difficulty turning
Limited ROM; ability to perform fine and gross motor skills
Movement-induced tremor, uncoordinated or jerky movements
Slowed and/or uncoordinated movements; reaction time.
Substitution of other behaviors for impaired mobility (for instance,
increased attention to others activity and controlling behavior)
RELATED FACTORS
Activity intolerance Decreased endurance; muscle
Altered cellular metabolism control, mass or strength
Body mass index above Depressive mood state
75th percentile Deficient knowledge about
Cognitive impairment value of exercise
Contractures Developmental delay
Cultural beliefs regarding Discomfort
age-appropriate activity Disuse
Deconditioning Joint stiffness
Activity/exercise
Neurocognition
EXPECTED OUTCOMES
The patient will
Be free from complications (e.g., contractures, venous stasis,
thrombus formation, skin breakdown, and hypostatic pneumonia).
Achieve the highest level of mobility (will transfer independently,
will be wheelchair-independent, or will ambulate with assistive
devices such as walker, cane, and braces).
Carry out mobility regimen.
Use resources to help maintain level of functioning.
Ambulation; Ambulation: Wheelchair; Joint Movement: Hip; Joint
Movement: Shoulder; Mobility; Transfer Performance
Determine: Identify level of functioning using a functional mobility
scale. Communicate patients skill level to all staff members to pro-
vide continuity and preserve identified level of independence.
Monitor and record daily any evidence of immobility
complications as they may be more prone to develop complications.
229
Perform: Perform ROM exercises to joints, unless contraindicated, at
least once every shift to prevent joint contractures and muscular
atrophy. Turn and reposition patient every 2 hr. Establish a turning
schedule and post at bedside. Monitor frequency of turning to pre-
vent skin breakdown by relieving pressure. Place joints in functional
position. Use trochanter roll along the thigh, abduct thighs, use
high-top sneakers, and pull a small pillow under patients head to
maintain joints in a functional position and prevent musculoskeletal
deformities.
Place items within reach of the unaffected arm if patient has one-
sided weakness or paralysis to promote patients independence.
Carry out medical regimen to manage or prevent complications
(e.g., administer prophylactic heparin for venous thrombosis). This
promotes patients health and well-being.
Provide progressive mobilization to the limits of patients
condition (bed mobility to chair mobility to ambulation) to maintain
muscle tone and prevent complications of immobility.
Inform: Instruct patient and family members in ROM exercises,
transfers, skin inspection, and mobility regimen to help prepare for
discharge and promote continuity of care. Request return
demonstration to ensure use of proper technique.
Attend: Help patient use a trapeze and side rails to encourage inde-
pendence in mobility. Instruct him to perform self-care activities to
increase muscle tone.
Encourage physical therapy sessions and support activities on the
unit by using the same equipment and technique. Request written
mobility plans for reference. Ensure all members of the healthcare
team are reinforcing learned skills in the same manner.
Manage: Refer patient to a physical therapist for development of
mobility regimen to help rehabilitate musculoskeletal deficits.
Assist patient in identifying resources such as American Heart
Association to provide a comprehensive approach to rehabilitation.
Exercise Promotion: Strength Training; Exercise Therapy: Joint
Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair
Reference
Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized
elderly. The Canadian Nurse, 101(6), 1620.
IMPAIRED WHEELCHAIR MOBILITY

DEFINITION
Limitation of independent operation of wheelchair within environment
Impaired ability to operate a manual or power wheelchair on curbs,
even surfaces, uneven surfaces, and/or an incline or a decline
RELATED FACTORS
Cognitive impairment Environmental constraints
Deconditioning Impaired vision
Deficient knowledge Limited endurance
Depressed mood Musculoskeletal impairment
Pharmacological function Neurocognition
EXPECTED OUTCOMES
The patient will
Have no complications associated with impaired wheelchair mobil-
ity, such as skin breakdown, contractures, venous stasis, thrombus
formation, depression, alteration in health maintenance, and falls.
Achieve the highest level of independence and safety possible with
regard to wheelchair use.
Express feelings regarding alteration in ability to use wheelchair.
Participate in social and occupational activities to the greatest
extent possible.
Demonstrate understanding of techniques to improve wheelchair
mobility.
Ambulation: Wheelchair; Balance; Mobility Level; Muscle Function
Determine: Assess wheelchair status: Seat is wide and deep enough
to support thighs, low enough for feet to touch the floor, yet high
enough to allow easy transfer from bed to chair; the back is tall
enough to support upper body; brakes on wheels lock; and seat belt
is present (may attach at waist, hips, or chest). Assessment ensures
chair meets patients physical needs (identifies need for modification),
promotes comfort, and prevents injuries (e.g., falls).
Assess patients level of strength in arms, and if chair is easy for
patient to operate when weak. This determines the need for a
motorized wheelchair to help maintain mobility and independence.
Identify patients level of independence using the functional mobil-
ity scale. Communicate findings to staff to promote continuity of
care and preserve the documented level of independence.
231
impaired wheelchair mobility. Patients with neuromuscular dysfunc-
tion are at risk for complications.
Assess patients skin on return to bed and request a wheelchair
cushion, if necessary, to maintain skin integrity.
Perform: Perform ROM exercises for affected joints, unless
contraindicated, at least once per shift. Progress from passive to
active ROM as tolerated. This prevents joint contractures and mus-
cle atrophy.
Inform: Explain to patient location of vulnerable pressure points and
instruct to shift and reposition weight to prevent skin breakdown.
Ensure patient maintains anatomically correct and functional body
positioning to promote comfort.
Demonstrate techniques to promote wheelchair mobility to the
patient and family members and note the date; have them perform a
return demonstration to ensure continuity of care and use of proper
technique.
Attend: Encourage patient to operate her wheelchair independently
to the limits imposed by her condition to maintain muscle tone,
prevent complications of immobility, and promote independence in
self-care and health maintenance skills.
Encourage attendance at physical therapy sessions and reinforce
prescribed activities on the unit by using equipment, devices, and
techniques used in the therapy session. To maintain continuity of
care and promote patient safety.
Manage: Refer patient to a physical therapist to enhance wheelchair
mobility and rehabilitation of musculoskeletal deficits.
Help patient identify resources for maintaining highest level of
mobility (e.g., community stroke program, sports associations for
people with disabilities, and the National Multiple Sclerosis Society)
to promote reintegration into the community.
Exercise Promotion: Strength Training; Exercise Therapy: Balance;
Exercise Therapy: Muscle Control; Positioning: Wheelchair
Reference
Gavin-Dreschnack, D., et al. (2005, AprilJune). Wheelchair-related falls: Cur-
rent evidence and directions for improved quality care. Journal of Nursing
Care Quality, 20(2), 119127.
NAUSEA
DEFINITION
A subjective unpleasant, wavelike sensation in the back of the throat,
epigastrium, or abdomen that may lead to the urge or need to vomit
Gagging sensation
Gastric stasis
Increased salivation, swallowing
Sour taste in the mouth
Uninterested in eating; does not have appetite
Reports nausea or sick to the stomach
RELATED FACTORS
Biophysical Situational
Biochemical disorders Anxiety
Esophageal disease Fear
Gastric distention, irritation Noxious odors, taste, visual
Increased intracranial pressure stimulation
Motion sickness Pain
Pain Physiological factors
Pancreatic disease Treatment
Tumors, intra-abdominal or Gastric distention, irritation
localized tumors Pharmaceuticals
Nutrition Knowledge
Fluid and electrolytes Comfort
EXPECTED OUTCOMES
The patient will
State reasons for nausea and vomiting.
Take steps to manage episodes of nausea and vomiting.
Ingest sufficient nutrients to maintain health.
Take steps to ensure adequate nutrition when nausea abates.
Maintain weight within specified limits.
Appetite; Comfort Level; Fluid Balance; Hydration; Nausea & Vom-
iting Control; Nutritional Status: Food & Fluid Intake; Suffering
Severity; Symptom Control
Determine: Assess for illness, pregnancy, medication use (prescription
and over-the-counter); exposure to tainted foods, chemicals, occupational
hazards; weight (fluctuation in last 6 months); food preferences and usual
dietary patterns; history of gastric/esophageal problems. Assessment infor-
mation will help in identifying appropriate interventions.
233
Monitor direct observation of food and fluid intake to ensure
whether or not the patient is receiving adequate nutritional intake.
Perform: Provide comfort measures (e.g., back massage, warm bath)
to promote feelings of comfort for the patient.
Reduce noise, control odors, and adjust light in the environment
to help the patient relax and to reduce environmental factors that
produce nausea.
Allow periods of uninterrupted sleep between procedures. Proce-
dures and medication administration sometimes trigger periods of
nausea.
Offer small amount of cool liquids or ice chips to provide some
fluid to reduce the possibility of dehydration.
Suggest frequent mouth care to reduce unpleasant taste in the
mouth.
Give dry, bland foods, such as dry toast or crackers, during peri-
ods of nausea to make it possible to eat. These foods have been
found to be effective.
Administer antinausea medications, as prescribed.
Inform: Teach relaxation techniques and encourage patient to use
these techniques during mealtime to reduce stress and divert atten-
tion from the nausea.
Teach patient how to use food and fluid during periods of nausea
to avoid dehydration and lack of nutrients. Food should be taken in
small, frequent feedings. Avoid drinking with meals.
Attend: When nausea abates, encourage patient to increase food
intake to assist with adequate intake of nutrients.
Assist patient to make a list of best tolerated and poorly tolerated
foods so he or she can choose quickly and wisely when nausea
abates.
Manage: If nausea persists, refer patient to a nutritionist to assist
after discharge to ensure that adequate nutrients will be ingested.
Stress the importance of follow-up appointments with the physi-
cian. Nausea is a preventable problem and should respond to appro-
priate measures.
Diet Staging; Fluid and Electrolyte Management; Fluid Monitoring;
Medication Management; Nausea Management Nutritional Manage-
ment
Reference
Mamaril, M. E., et al. (2006, December). Prevention and management of
postoperative nausea and vomiting: A look at contemporary techniques.
Journal of Perianesthesia Nursing, 21(6), 404410.
UNILATERAL NEGLECT
DEFINITION
Impairment in sensory and motor response, mental representation,
and spatial attention of the body and the corresponding environ-
ment characterized by inattention to one side and overattention to
the opposite side. Left side neglect is more severe and persistent
than right side neglect
Consistent inattention to stimuli/positioning on affected side
Failure to eat food on plate on the affected side
Inadequate self-care
Failure to move eyes, head, limbs, or trunk in the affected hemi-
space despite awareness of stimulus in that space
Marked deviation of the eyes, head, or trunk to the nonaffected
side by stimuli and activities on that side (as if drawn by Magnet)
Perseveration of visual motor tasks on the nonaffected side
RELATED FACTORS
Brain injury from tumor, or cerebrovascular, neurological, or trau-
matic causes
Left hemiplegia from CVA of right hemisphere
Hemianopsia
Activity/exercise Self-care
Coping Sensation/perception
Neurocognition Tissue integrity
EXPECTED OUTCOMES
Avoid injury, skin breakdown and contractures on affected body part.
Recognize the neglected body part.
Demonstrate exercises for the affected body part.
Demonstrate measures for maximum functioning and arrange
environment to protect the affected body part.
Express feelings about altered state of health and neurologic deficits.
Identify community resources and support groups to help cope
with the effects of illness.
Adaptation to Physical Disability; Body Image; Body Mechanics Per-
formance; Body Positioning: Self-Initiated; Self-Care: ADLs
Determine: Observe the position of the affected body part frequently
to prevent injury.
Perform: Place a sling on the affected arm to prevent dangling or injury.
Support affected leg and foot and perform other measures, as
appropriate, to keep patients limbs in functional position and avoid
235
contractures. Use a drawsheet to move patient up in bed to avoid
skin abrasions.
Touch and rub the affected limb, and describe the limb in conversa-
tion with patient. This reminds the patient of the neglected body part.
Use safety belts or protective devices to remind patient of limita-
tions and prevent falls. Use devices according to facility policy.
Remove splints and other devices at least every 2 hr. Inspect the
skin for pressure areas. Reapply the splint. Proper use of splints and
other devices prevents deformities and maintains skin integrity.
Perform ROM exercises on the affected side at least once every
shift, unless medically contraindicated, to maintain joint flexibility
and prevent contractures. Establish and follow a regular turning
schedule to maintain skin integrity.
Arrange environment for maximum functioning; for example,
place water, television controls, and the call bell within reach. These
measures enhance orientation and encourage independence.
Assist patient with ADLs or provide supervision, as appropriate,
to protect patients affected side.
Inform: Encourage patient to perform activities that require use of
the affected limb to more easily integrate paretic or paralyzed limb
into body image.
Instruct family and nursing personnel to observe the position of
the affected body part frequently; to remove food or drainage from
the face if unnoticed by patient; and to place the arm or leg in the
proper position as often as necessary. These measures help avoid
injury and maintain dignity.
Attend: Encourage patient to check the position of the affected body
part with each repositioning or transfer to reestablish awareness of
the body part.
Encourage patient and family members to express their feelings
regarding patients condition and level of functioning to release ten-
sion and enhance coping.
Manage: Request consultations with occupational and physical ther-
apists about adaptive equipment and exercise programs to promote
use of the affected limb.
Refer patient and family members to appropriate support groups
and other community resources to assist in adjusting to patients
altered state of health.
Body Image Enhancement; Exercise Therapy: Joint Mobility; Mutual
Goal-Setting; Self-Care Assistance; Unilateral Neglect Management
Reference
Macko, R. F., et al. (2005, Winter). Task-oriented aerobic exercise in chronic
hemiparetic stroke: Training protocols and treatment effects. Topics in
Stroke Rehabilitation, 12(1), 4557.
NONCOMPLIANCE
DEFINITION
Behavior of person and/or caregiver that fails to coincide with a
health-promoting or therapeutic plan agreed on by the person
(and/or family and/or community) and health-care professional. In
the presence of an agreed-on, health-promoting or therapeutic plan,
persons or caregivers behavior is fully or partially nonadherent and
may lead to clinically ineffective or partially ineffective outcomes
Behavior indicative of failure to progress
Complications or evidence of exacerbation of signs and symptoms
Failure to keep appointments and adhere to treatment regimen
Objective indications (e.g., laboratory tests, physiologic markers)
RELATED FACTORS
Health system Individual
Access to, convenience of care Cultural/spiritual values
Clientprovider relationships Developmental and personal
Individual health coverage abilities
Provider communication skills, Health beliefs
credibility; continuity; teaching Knowledge of regimen
skills; reimbursement Motivational forces
Healthcare plan Network
Complexity, intensity Involvement of members in
Cost, financial flexibility, and health plan
duration of plan Social value regarding plan
Behavior Knowledge
Beliefs/values Roles/responsibilities
Emotional status
EXPECTED OUTCOMES
The patient will
Identify factors that influence noncompliance.
Demonstrate level of compliance that maintains safety.
Contract to perform specific behaviors.
Use support systems to modify noncompliant behaviors.
Acceptance: Health Status; Adherence Behavior; Compliance Behav-
ior; Symptom control; Treatment Behavior
Determine: Assess patients perception of health problem, treatment
regimen and history of compliance, obstacles to compliance, financial
237
resources, ethnicity, and religious influences. Assessment information
may help select appropriate interventions.
Perform: Provide an environment that is nonjudgmental. This
demonstrates unconditional respect for the patient.
Contract with the patient to practice only nonthreatening behav-
iors. This involves the patient in a formal commitment and gives the
patient a sense of personal control.
such as meditation, guided imagery, yoga, and prayer. These
techniques promote self-reliance.
Teach principles of good nutrition for patients specific condition.
Understanding importance of nutrition will encourage compliance.
Inform patient about diagnosis. Understanding essential informa-
tion needed to perform skills or give self-care increases compliance.
Demonstrate skills needed by patient to comply with treatment regi-
men to reinforce patients confidence in ability to replicate.
Attend: Provide opportunities for the patient to discuss reasons for
noncompliance. The willingness of the nurse to listen allows the
patient the ability to listen to his or her own reasoning.
Help patient clarify his or her values about the importance of fol-
lowing a treatment plan to determine appropriate interventions.
Acknowledge patients right to choose not to comply with
prescribed regimen to respect autonomy. Control over patient's
actions is legitimate only when dangerous to self or others. Offer
positive reinforcement.
Use support systems to reinforce negotiated behaviors. Support
from the family and friends help foster compliance.
Manage: When medically appropriate, support patients cultural
beliefs towards medical practices to demonstrate respect; and refer
to a member of the clergy or a spiritual counselor.
Refer family to community resources and support groups to pro-
mote compliance with modification of behavior. If patients situation
is complicated by lack of financial resources, contact agencies that
may offer help with costs of medical treatment.
Coping Enhancement; Counseling; Decision-Making Support; Health
Education; Patient Contracting; Self-Modification Assistance; Self-
Responsibility Facilitation
Reference
Riegel, B., et al. (2006, MayJune). A motivational counseling approach to
improving heart failure self-care mechanisms of effectiveness. Journal of
Cardiovascular Nursing, 21(3), 232241.
IMBALANCED NUTRITION: LESS THAN BODY

REQUIREMENTS
DEFINITION
Intake of nutrients insufficient to meet metabolic needs
Abdominal pain, cramping
Altered taste sensation; aversion to or lack of interest in eating
Body weight 20% under ideal weight
Diarrhea or steatorrhea
Excessive hair loss
Fragile capillaries
Hyperactive bowel sounds
Lack of information, misconceptions, or misinformation
Loss of body weight despite adequate food intake
Pale conjunctiva and mucous
Perceived inability to digest or ingest food
Satiety immediately after ingesting food
Weakness of muscle required for chewing or swallowing
RELATED FACTORS
Biological factors Inability to digest/ingest food
Economic factors Physiologic factors
Inability to absorb nutrients
Behavior Elimination
Coping Fluids and electrolytes
Nutrition Values/beliefs
EXPECTED OUTCOMES
The patient will
Consume ____ calories daily.
Gain __ pounds per week and show no further evidence of weight
loss.
Communicate understanding of dietary needs.
Demonstrate ability to plan meals that will help patient gain weight.
Nutritional Status; Nutritional Status: Food & Fluid Intake; Nutri-
tional Status: Nutrient Intake; Weight Control
Determine: Assess height, weight, meal preparation, serum albumen,
usual dietary pattern, weight fluctuation over the last 10 years, psy-
chosocial status, and coping behavior. Assessment of these factors
will allow the nurse to choose appropriate interventions.
Perform: Obtain and record patients weight everyday at the same
time to ensure keeping an accurate record of weight.
Monitor fluid intake and output every 8 hr to provide adequate
fluid replacement.
239
Provide a diet prescribed for the patients specific condition and
preferences to ensure that the patients dietary restrictions are
followed as much as possible. Keep snacks at the bedside to allow
the patient to eat small amounts frequently.
Approach patient in a nonjudgmental manner. This demonstrates
unconditional positive respect for the patient. Facilitate opportunities
for spiritual nourishment and growth to address patients holistic
needs for maximal therapeutic environment.
such as meditation, guided imagery, yoga, and prayer. Teach patient
usual daily activities. These techniques can be used to reduce anxiety
and increase self-reliance.
Provide patient with concise information about the diagnosis, and
teach principles of good nutrition for specific condition. Understand-
ing encourages compliance with treatment and nutritional regimen.
Attend: Provide opportunities for the patient to discuss reasons for
not eating and to clarify values about the importance of food in
order to determine appropriate interventions.
After obtaining patients food preferences, attempt to obtain
desired foods for the patient. Offer food that appeal to olfactory,
visual, and tactile senses to enhance patients appetite. Whenever
possible, sit with patient for a predetermined time during each meal.
This inhibits patient from dawdling during the meal.
Acknowledge patients right to choose not to comply with prescribed
regimen. Patients autonomy must be respected. Control over patients
actions is legitimate only when danger is posed to patient or others.
Use support systems to reinforce negotiated behaviors. Support
from the family helps foster compliance.
Manage: Refer patient to a dietitian or nutritional support team for
dietary management. Refer family to community resources and sup-
port groups available to assist patient in complying with modifica-
tion of behavior. If patients situation is complicated by a lack of
financial recourses, contact agencies that may offer help with the
cost of medical treatment. Refer to a member of the clergy or a
spiritual counselor, according to the patients preference, to show
respect for the patients beliefs and provide spiritual care.
Diet Staging; Eating Disorders Management; Fluid Monitoring;
Mutual Goal-Setting; Weight Goal-Setting
References
Corcoran, L. (2005, NovemberDecember). Nutrition and hydration tips for
stroke patients with dysphagia. Nursing Times, 101(48), 2447.
Ellet, M. L. (2006, MarchApril). Important facts about intestinal feeding
tube placement. Gastroenterology Nursing, 29(2), 112124.
IMBALANCED NUTRITION: MORE THAN

BODY REQUIREMENTS
DEFINITION
Intake of nutrients that exceed metabolic needs
Body weight 20% above ideal body weight
Dysfunctional eating patterns, such as concentrating food intake at
the end of the day, eating in response to internal cues other than
hunger, eating in response to external cues, and pairing food with
other activities
Sedentary lifestyle
Triceps skin fold greater than 15 mm in men and 25 mm in women
RELATED FACTORS
Excessive intake related to metabolic needs
Behavior Knowledge
Communication Nutrition
Emotional
EXPECTED OUTCOMES
The patient will
Voice feelings about present weight.
Identify internal and external cues that increase food consumption.
Verbalize need to lose weight.
Set a goal of losing ____ pounds a week.
Adhere to prescribed diet, and plan menus appropriate to diet.
Set target weight before discharge.
State plan to monitor and maintain target weight.
Participate in an exercise plan ___ times per week.
Adherence Behavior; Knowledge: Diet; Motivation; Nutritional Sta-
tus; Risk Detection; Stress Level; Weight Control
Determine: Assess height, weight, usual dietary patterns, food prefer-
ence, understanding of risk factors, heredity influences, activity level,
usual coping patterns, body image. Information from assessment will
help identify appropriate interventions.
Perform: Weigh patient weekly, or as ordered to evaluate patients
progress toward reaching goal and provide feedback.
Help patient set realistic goal for weight loss. Goal should be in
the ideal range considering the patients height and age, but the
patient needs to be reminded that slow weight loss will help him or
her reach his or her goal more effectively.
241
Inform: Teach patient about low-calorie, nutritious foods. This
encourages patient to eat foods that provide energy without causing
weight gain.
Have patient keep a food diary in order to keep track of what is
actually eaten. Without this, foods are sometimes eaten and not
included in daily food consumption. This will act a self-monitoring
tool.
Teach coping skills. Have patient role-play to provide practical
experience. Provide instructional material on healthy eating habits,
coping skills, self-esteem, and so forth.
Attend: Listen to patients personal values and beliefs, but remain
nonjudgmental, even if his or her values and beliefs differ from your
own. Remaining nonjudgmental, but attentive, shows your support.
Explore personal identity issues distressing to the patient to isolate
issues into small, more solvable units.
Help patient identify his or her values, beliefs, hopes, dreams
skills, and interest. The patients deficits may lie in a lack of self-
exploration or problem-solving methods used.
Promote choices with the most likeliness of success. Specific
instructions can help the patient gain problem-solving ability and
maturity.
Manage: Refer patient to a mental health professional for behavior
modification to help change poor eating habits and ensure
permanent weight loss.
Have a dietitian calculate the caloric intake the patient will
require to reach a desirable weight to allow for planning.
Refer to peer support groups, and promote outpatient counseling
and family meetings to reinforce progress and reduce regression.
Behavior Management; Behavior Modification; Coping Enhancement;
Eating Disorders Management; Exercise Promotion; Limit Setting;
Nutrition Management; Weight Reduction Assistance
Reference
Daggett, L. M., & Rigdon, K. I. (2006, spring). A computer-assisted instruc-
tional program for teaching portion size versus serving size. Journal of
Community, 23(1), 2935.
READINESS FOR ENHANCED NUTRITION

DEFINITION
A pattern of nutrient intake that is sufficient for meeting metabolic
needs and can be strengthened
Attitude toward drinking and eating is congruent with health goals
Consumes adequate fluid and food on regular basis
Expresses knowledge of healthy fluid and food choices
Expresses willingness to enhance nutrition
Follows an appropriate standard for intake
Safely prepares fluids and foods
Safely stores fluids and foods
Knowledge Risk management
Nutrition Values/beliefs
EXPECTED OUTCOMES
The patient will
Articulate present understanding of factors that enable and hinder
enhanced nutritional status.
Evaluate each of the barriers to enhancing nutritional status.
Articulate the personal value of practicing positive behaviors.
Plan modifications of environment to reinforce change in eating
habits.
Express positive feelings about himself.
Adherence Behavior: Healthy Diet; Knowledge: Diet; Knowledge:
Weight Management; Nutritional Status: Fluid and Food Intake
Determine: Assess height, weight, body mass index; self-esteem, atti-
tude toward food and eating; moral or health concerns about eating;
financial status; cultural background and influences of same on food;
ability to read food labels, numbers of take-out meals per week;
cost of food in particular geographic area. Assessment information
about these factors will help identify appropriate interventions.
Perform: Help patient list the internal and external barriers to
improving nutritional status. Lack of understanding of the patients
individual barriers, such as unclear goals, lack of skill, or lack of
motivation will prevent change from occurring.
Inform: Provide materials that are intellectually and culturally appro-
priate for enhancing nutritional knowledge. It is important to
engage the patient in information gathering before beginning to
develop a plan to change behavior.
243
Teach patient to read food labels, to plan meals using a standard
method such as the meals in the Food Guide (American Diabetic
Association) and to stop and stock the refrigerator and pantry with
smart food choices. New behaviors require practice in a practical
sense for the kind of reinforcement that will produce the desired
change.
Teach patient about the importance of exercise. Assist patient to
outline a realistic program that provides adequate exercise on a
weekly basis. Having a schedule that is realistic for the individual
will assist the patient with personal compliance.
Attend: Encourage patient to list realistic goals with target dates for
meeting. Goal-directed behavior will increase the chance of positive
outcomes.
Have patient make a list of the positive outcomes of changing
behaviors (e.g., wearing smaller size clothing, feeling better about
being with others who are health conscious, enjoying feelings of
physical and emotional well-being). Positive reinforcers make
changes more appealing.
Manage: Refer patient to a nutrition group and an exercise group in
the community, and community resources that may offer assistance
to the patient when needed. Patients often do better when they are
participating with others who are working toward similar goals.
Having written instructions reinforces learning.
Nutrition Management; Weight Management; Risk Factor Control;
Teaching
Reference
Werrij, M. Q., et al. (2006, July). Overweight and obesity: The significance of
a depressed mood. Patient Education and Counseling, 62(1), 126131.
RISK FOR IMBALANCED NUTRITION: MORE

THAN BODY REQUIREMENTS
DEFINITION
At risk for intake of nutrients that exceeds metabolic needs
RISK FACTORS
Consumption of solid food High baseline weight at the
as a major source before beginning of pregnancy
5 months of age Obesity of one or more parents
Dysfunctional eating patterns, Rapid movement across
such as concentrating food growth percentiles
intake at the end of the day,
using food as a reward, eating
in response to external cues
Activity Nutrition
EXPECTED OUTCOMES
The patient will
Express need to stabilize weight within 510 pounds of target
weight.
Plan to monitor weight and sustain target weight.
Express feelings regarding dietary regimen and current weight.
Identify internal and external cues that lead to increased food
consumption.
Plan menus that are appropriate for prescribed diet.
Participate in selected exercise program every week.
Knowledge: Diet; Nutritional Status; Nutritional Status: Nutrient
Intake; Risk Control; Stress Level; Weight Control
Determine: Assess nutritional history, usual dietary habits, frequency
and size of meals, snacks, meal preparation; meals eaten out or
take-out per week. Assess weight, weight fluctuation over past year;
activity level, body image; motivation to modify lifestyle. Informa-
tion from the assessment will help identify appropriate interventions.
Perform: Weigh patient weekly or as prescribed to monitor the effec-
tiveness of the diet and provide feedback to the patient.
Establish, with the patient, a realistic target weight, and help
patient take an active role in healthcare decisions. The greater the
role the patient takes, the more likely he will succeed in reaching
the goal.
Determine food preferences to evaluate eating habits and to
include preferred food on the patients list if they are nutritious.
This will help the patient make healthful choices.
245
Inform: Teach the basics of meal planning using the Food Guide
Pyramid found at www.MYPyramid.gov to help patients find food
types and calories needed to remain on target.
Give written materials and use visuals, discussion, and role-play-
ing to help the patient learn to make healthy food selection. Use a
variety of media to make important points.
Teach the importance of incorporating exercise into lifestyle. Help
patient select a program with various activities (such as swimming,
walking, cycling, aerobics) appropriate for age and physical condi-
tion. Exercise burns calories, offers an alternative to eating to allevi-
ate stress, and fosters a sense of accomplishment.
Attend: Give patient emotional support and positive feedback for
adhering to the prescribed die. This will foster compliance and help
ensure adherence to weight program.
Manage: Refer patient to an appropriate resource for behavior mod-
ification and cognitive therapy to prevent relapse into high-risk eat-
ing behaviors.
If patient has new insights in his or her motivation to reduce his
weight, encourage him or her to share this information with his pri-
mary healthcare practitioner to foster a sense of responsibility for
obtaining healthcare.
Suggest that patient present practitioner with a summary of his or
her goals and the strategies to meet them. As patients move from
one physician to another, information about the patients problems
and goal to resolve and progress in doing the same often get lost. In
this way the patient takes responsibility for bringing his or her pri-
mary care practitioner up to date with his or her progress.
Recommend that the patient explore group diet therapies, such as
Weight Watchers and Overeaters Anonymous, to provide additional
sources of information and encouragement.
Behavior Management; Exercise Promotion; Nutritional Counseling;
Nutrition Management; Teaching; Prescribed Diet
Reference
Werrij, M. Q., et al. (2006, July). Overweight and obesity: The significance of
a depressed mood. Patient Education and Counseling, 62(1), 126131.
IMPAIRED ORAL MUCOUS MEMBRANE

DEFINITION
Disruption of the lips and/or soft tissue of the oral cavity
Bleeding Gingival or mucosal pallor
Coated tongue Halitosis
Desquamation Mucosal denudation
Difficulty eating, speaking, or Oral lesions, ulcers, pain, or
swallowing discomfort
Diminished, absent, or bad Purulent drainage or exudate;
taste presence of pathogens
Dry mouth Smooth, atrophic, sensitive
Edema tongue
Enlarged tonsils Spongy patches or white, cur-
Fissures and chelitis dlike exudate
Gingival hyperplasia or Stomatitis
recession (pockets deeper than Vesicles, nodules, or papules
4 mm) White patches and plaque
RELATED FACTORS
Barriers to oral self or profes- Mechanical factors (braces,
sional care dentures)
Chemical irritants (e.g., Ineffective oral hygiene
alcohol, drugs, regular use Malnutrition
of inhalers) Dehydration
Chemotherapy Stress
Cleft lip and/or palate Trauma
Coping Nutrition
Fluid and electrolytes Tissue integrity
EXPECTED OUTCOMES
The patient will
Maintain fluid balance (intake equals output).
Have pink, moist oral mucous membranes.
Have minimal, if any, complications of the oral mucosa.
Correlate precipitating factors with appropriate oral care.
Demonstrate oral hygiene practices.
Oral Hygiene; Tissue Integrity: Skin & Mucous Membranes
Determine: Inspect patients oral cavity every shift. Describe and
document condition; report any change in status. Regular
assessments can anticipate or alleviate problems.
247
Monitor progress, reporting favorable and adverse responses to the
treatment regimen to evaluate effectiveness.
Perform: Perform the prescribed treatment regimen, including admin-
istering intravenous or oral fluids, to improve the condition of
patients mucous membranes.
Provide supportive measures, as indicated:
Assist with oral hygiene before and after meals to promote a
feeling of comfort and well-being.
Use a toothbrush with suction if patient cant spit out water to
minimize risk of aspiration.
Provide mouthwash or gargles, as ordered, to increase patient
comfort and maintain moisture in his or her mouth.
Lubricate patients lips frequently with water-based lubricant to pre-
vent cracked, irritated skin. These measures improve oral health.
Inform: Instruct patient in oral hygiene practices, if necessary. Have
patient return a demonstration of the oral care routine.
Use a soft-bristled toothbrush.
Brush with a circular motion away from the gums.
Include the tongue when brushing.
Review the need for routine visits to a dentist (annually for
adults).
These measures increase patients awareness of oral hygiene practices
and reduce discomfort, resulting in increased nutrition and hydration.
Tell patient to chew gum or suck on sugarless hard candy to stim-
ulate salivation.
Discuss precipitating factors, if known, and work to prevent
future episodes. For example, encourage patient to avoid exercising
in heat and to report effects of medication. Patients increased
awareness of causative factors will help prevent recurrence.
Attend: Encourage adherence to other aspects of healthcare manage-
ment (controlling diabetes, changing dietary habits, and avoiding alco-
holic beverages) to control or minimize effects on mucous membranes.
Manage: Refer patient to a dentist, dental hygienist, or other appro-
priate resource to correct ill-fitting dentures, modify braces, and
adjust jaw wires as needed. Regularly scheduled dental follow-up
reduces the risk of trauma to oral mucous membranes.
Fluid and Electrolyte Management; Oral Health Maintenance; Oral
Health Restoration
Reference
Bailey, R., et al. (2005, July). The oral health of older adults: An interdiscipli-
nary mandate. Journal of Gerontological Nursing, 31(7), 1117.
ACUTE PAIN
DEFINITION
Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage (Inter-
national Association for the Study of Pain); sudden or slow onset of
any intensity from mild to severe with an anticipated or predictable
end and a duration of less than 6 months
Alteration in muscle tone Expression of pain (such
Autonomic responses as moaning or crying)
Changes in appetite and eating Facial mask of pain
Communication (verbal or Guarding or protective
coded) of pain behavior
Distracting behavior (such as Narrowed focus
pacing, seeking out other peo- Self-focusing
ple, and performing repetitive Sleep disturbance
activities)
RELATED FACTORS
Injury agents (biological, chemical, physical, psychological)
Communication Sleep/rest
Emotional
EXPECTED OUTCOMES
The patient will
Rate pain on a scale of 110. Decrease amount and frequency
Articulate factors that intensify of pain medication needed.
pain and will modify Express feeling of comfort and
behaviors accordingly. relief from pain.
State and carry out appropriate Perform relaxation exercises at
interventions for relief of pain. bedtime.
Comfort Level; Pain Control; Pain; Disruptive Effects; Pain Level;
Sleep: Activity
Determine: Assess descriptive characteristics of pain, including loca-
tion, quality and intensity on a scale of 110, temporal factors and
sources of relief; pain tolerance; ethnicity; attitude and values.
Descriptions about the particulars of pain will help determine what
goals are realistic for the patient.
Perform: Make changes in the environment at the patients
suggestion that will promote sleep. This allows patient to have an
active role in treatment.
249
Apply heat or cold as prescribed to minimize or relieve pain.
Reposition patient and use pillows to splint or support painful areas,
as appropriate to reduce muscle spasm and to redistribute pressure
on body parts. Administer analgesic medications in a collaborative
mode with the patient when alternative methods are not sufficient to
make the pain tolerable. Gaining the patients trust and involvement
helps ensure compliance and make reduce medication intake.
Provide patient with sleep aids, such as pillows, bath before sleep,
and reading materials. Milk and some high-protein snacks, such as
cheese and nuts, contain L-tryptophan and are also sleep promoters.
Personal hygiene and prebedtime rituals promote sleep in some
patients. Comfort measures act as distracters from pain, reduce mus-
cle tension or spasm, and redistribute pressure on body parts.
relaxation. Practice with the patient frequently and especially at bed-
time. Purposeful relaxation efforts usually help promote sleep.
and beverages containing caffeine consumed fewer than 4 hours
before bedtime may interfere with sleep. Alcohol disrupts normal
sleep, especially when ingested immediately before retiring.
Attend: Listen to patients description of pain. Allow time for the
patient to talk about his or her frustration. Listening attentively
gives the patient a feeling that the nurse is interested. It also helps
determine progress in alleviating the pain.
Ask patient each day to describe the quality of his or her sleep.
Discomfort associated with pain may prevent the patient from sleep-
ing well.
Encourage activities that provide distraction, such as reading, crafts,
television, and visits to help patient focus on non-pain-related matters.
Manage: When possible, allow patient to use alternative pain treat-
ments common in his or her culture (such as acupuncture) as a sub-
stitute or a complement to Western treatments to promote nonphar-
macologic pain management
Refer to case manager/social worker to ensure that follow-up is
provided.
Coping Enhancement; Emotional Support; Medication Management;
Pain Management; Positioning; Sleep Enhancement
Reference
DeJong, A. E., & Gamel, C. (2006, June). Use of simple relaxation technique
in burn care: Literature review. Journal of Advanced Nursing, 54(6),
710721.
CHRONIC PAIN
DEFINITION
Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage (Interna-
tional Association for the Study of Pain); sudden or slow onset of any
intensity from mild to severe, constant or recurring without an antici-
pated or predictable end and a durtion of greater than 6 months
Altered ability to continue Fear of injury
usual activity Irritability
Atrophy of involved muscle Protective or guarding behavior
group Reduced social action
Changes in sleep pattern Restlessness
Depression Self-focusing
Face mask Weight gain or loss
Fatigue
RELATED FACTORS
Chronic physical disability
Chronic psychological disability
Cardiac functioning Neurocognitive functioning
Comfort Pharmacologic function
Coping Respiratory functioning
EXPECTED OUTCOMES
The patient will
Identify characteristics of pain and pain behaviors.
Develop pain management that includes activity and rest, exercise,
and medication regimen that isnt pain contingent.
Carry out resocialization behaviors and activities.
State relationship of increasing pain to stress, activity, and fatigue.
State importance of self-care behavior or activities.
Comfort Level; Depression; Depression Self-Control; Pain Control;
Pain Level; Quality of Life; Sleep; Symptom Control
Determine: Assess descriptive characteristics of pain, including location,
quality, intensity on a scale of 110, temporal factors and sources of
relief; pain tolerance; ethnicity; self-image, coping behaviors, sleep pat-
terns, activity level, attitude, and values. Assessment will provide infor-
mation to help identify interventions for that specific patient.
Perform: Set up a behavior-oriented plan; for instance, set up a plan
to follow the activity schedule. Behavioralcognitive measures can
help patient modify learned pain behaviors.
251
Contract with patient to increase probability that he or she will
follow the plan for pain management that has been developed with
him. A contract is an agreement that can always be referred to
when the patient attempts to make decisions outside the provisions
of the plan.
Schedule self-care activities for the patient. This reduces depend-
ence on caregivers and others in the patients environment.
Administer analgesic pain medication as outlined in the plan.
When a patient requests more than the plan allows, reiterate the
terms of the plan in order not to overmedicate.
relaxation. Practice with the patient frequently and especially at bed-
time. Purposeful relaxation efforts may help promote sleep.
and beverages containing caffeine consumed fewer than 4 hr before
bedtime may interfere with sleep. Alcohol disrupts normal sleep,
especially when ingested immediately before retiring.
Attend: Work closely with staff and family to achieve pain manage-
ment goals and maximize the patients cooperation.
Encourage patient and family to express feelings associated with
diagnosis, treatment, and recovery to help patient and family cope
with treatment. Schedule time to spend with the patients family.
They need time with healthcare providers to ask questions.
Encourage activities that provide distraction, such as reading, crafts,
television, and visits to help patient focus on non-pain-related matters.
Manage: When possible, allow patient to use alternative pain treat-
ments common in his or her culture (such as acupuncture) as a sub-
stitute or a complement to Western treatments to promote nonphar-
macologic pain management.
Arrange for frequent multidisciplinary/family care conference to
keep care goal-oriented. Refer patient to support group to help deal
with pain, depression, etc. Refer to social worker/case manager for
follow-up care.
Analgesic Administration; Behavior Modification; Emotional
Support; Mood Management; Pain Management; Patient Contract-
ing; Simple Massage
Reference
Siedlecki, S. L. (2006, September). Predictors of self-rated health status in
patients with chronic nonmalignant pain. Pain Management Nursing, 7(3),
109116.
READINESS FOR ENHANCED PARENTING

DEFINITION
A pattern of providing an environment for children or other depend-
ent person(s) that is sufficient to nurture growth and development
and can be strengthened
Evidence of bonding or Satisfaction with home
attachment environment
Fulfillment of physical and Willingness to enhance
emotional needs parenting
Realistic expectations
Communication Roles/responsibilities
Knowledge
EXPECTED OUTCOMES
The parents will
Express satisfaction with and confidence in parental role.
Discuss signs of safe and functional environment in the home
setting and state or demonstrate an understanding of teaching.
Demonstrate consistency and effectiveness related to discipline.
The family will
Appear to be physically and emotionally healthy.
Express belief in a higher spiritual power.
Express enjoyment of spending time together.
Express confidence in social and community resources available
related to family needs.
ParentInfant Attachment; Parenting: Psychosocial
Determine: Assess age and maturity of the parents; parental role-mod-
els during childhood; role satisfaction; social support; educational
needs of parents, present parenting skills, coping mechanism utilized,
knowledge of child growth and development, disciplinary methods
used by parents. Family status, including relationship between parents
and parents to children, sibling relationships, and spirituality. Psycho-
logical status, including financial, educational level, and consistency
and reliability of parenting techniques. A thorough assessment will
help identify appropriate interventions for this diagnosis.
Perform: Explore familys value systems as well as their spiritual
beliefs and practices. Spirituality and values provide a basis for ethi-
cal and moral reasoning and an enhanced meaning to life.
Explore parents idea of social support and community resources
available to the family to prepare for later referrals.
253
Establish an environment of mutual trust and respect to enhance
learning. Consistency between action and words combined with the
parents self-awareness forms the basis of a trusting relationship.
Inform: Select teaching strategies that will enhance teaching/learning
effectiveness, such as discussion, demonstration, role-playing, and
visual materials. Teach those skills that the patient must incorporate
into daily living. Have patient do return demonstration of each skill
to aid in gaining confidence.
cognition, parents will be better prepared to cope. Include family
members in teaching. Demonstrate to family members how each
coping strategies can be used to deal with challenging incidents.
Attend: Engage parents in a discussion of discipline practices and
offer suggestions to enhance their present skills. Discipline needs to
be consistent and loving and have reasonable guidelines. Children
want and need to have limits in order to feel safe.
Encourage family to play together. Laughter and joy increase
enjoyment and bonding as well as growth as a family unit.
Praise family for activities and traditions they honor together.
Sharing meaningful activities increases loyalty, security, and a sense
of belonging for family members. Encourage family members to par-
ticipate in patients learning process to help create a therapeutic
environment after discharge.
Demonstrate patience in helping the patient repeat new skills mul-
tiple times. Offer parents opportunities to express their doubts or
convictions about the adequacy of their parenting skills. An open
and receptive attitude provides an atmosphere for increased trust
and enhanced learning.
Manage: Have patient incorporate learned skills into care while still
in the hospital to allow practice and time for feedback.
Provide patient and/or family with names and telephone numbers
of resource people or community agencies so that care is continuous
and follow-up is possible after discharge.
If financial hardship interferes with the familys ability to provide
equipment and supplies, offer a referral to a social worker to
improve the familys access to financial assistance.
Attachment Promotion; Developmental Enhancement: Child; Family
Integrity Promotion: Childbearing Family; Environmental Management:
Attachment Process; Family Integrity Promotion; Role Enhancement
Reference
Gage, J. D., et al. (2006). Integrative review of parenting in nursing research.
Journal of Nursing Scholarship, 389(1), 5662.
IMPAIRED PARENTING
DEFINITION
Inability of the primary caretaker to create, maintain, or regain an
environment that promotes the optimum growth and development of
the child
Infant or child
Behavioral disorders, failure to thrive, frequent accidents and illness
History of trauma or abuse
Lack of attachment, no separation anxiety, poor social competence
Parental
Parents inflexibility in meeting childs needs
Evidence of negligent behavior toward or abandonment of child
Expressed frustration over inability to control child
Expressed inability to meet childs needs
Poor or inappropriate caregiving skills
Poor parentchild interaction
Rejection or hostility toward child.
RELATED FACTORS
Altered perceptual abilities Lack of education
Attention-deficit/hyperactivity Maladaptive coping strategies
disorder Multiple births
Deficient knowledge about Premature birth
parenting skills Separation from parent
Developmental delay Sleep disruption
Knowledge Values and beliefs
Risk management
EXPECTED OUTCOMES
The parents will
Make appropriate physical, verbal, and eye contact when interact-
ing with infant or a child.
Make statements indicating satisfaction with infant or child.
Demonstrate correct feeding, bathing, and dressing techniques.
Express willingness to maintain their relationship with each other.
Bring infant for routine well-child care.
Coping Enhancement; Family Process Maintenance; Parent Education
Determine: Assess developmental state; interaction between parent
and child; financial status; work demands; support systems, parents
255
knowledge of child. Assessment of these factors will help identify
appropriate interventions for this diagnosis.
Perform: Act as a role model for parenting when caring for the child
in the presence of the parents. Lack of knowledge of routine child
care practices, as well as growth and developmental norms, signifi-
cantly contributes to child abuse.
Involve patents in the care of the child immediately to promote
attachment to the child.
a motivation for the parents to search further.
Direct patient to use other sources such as libraries, Internet, or
professional organizations. An independent search results in the par-
ents developing confidence. Select teaching strategies that will
enhance teaching/learning effectiveness, such as discussion, demon-
stration, role-playing, visual materials.
Teach those skills that the patient must incorporate into ability to
go much deeper into the area of interest.
cerns related to the knowledge and skills that parents need. This
promotes greater ease in managing challenging situations.
Demonstrate willingness to repeat instruction and demonstrations
of skills needed by parents. Be available to answer questions and
correct misconceptions for parents to enhance the effectiveness of
learning.
Manage: Refer to social and community resources for ongoing assis-
tance with parenting. The parents can contact these sources for
additional information as needed.
Coping Enhancement; Family Process Maintenance; Family Support;
Mutual Goal-Setting; Learning Facilitation; Learning Enhancement;
Role Enhancement
Reference
Tucker, S., et al. (2006, SeptemberOctober). Lessons learned in translating
research evidence on early intervention programs in clinical care. The Amer-
ican Journal of Maternal Child Nursing, 31(5), 325331.
RISK FOR IMPAIRED PARENTING

DEFINITION
Risk for inability of the primary caretaker to create, maintain, or
regain an environment that promotes the optimum growth and
development of the child
RISK FACTORS
Change in family unit Lack of cognitive readiness for
Chronic low self-esteem parenthood
Depression Lack of family cohesiveness
Disability Lack of poor parental role model
Father of child not involved Lack of social support
Financial difficulties network
History of being abused Lack of transportation
Inability to put childs needs Legal difficulties
above own Maladaptive coping strategies
Inadequate child care arrange- Poor home environment
ments Role strain or overload
Coping Behavioral
Roles/responsibility Knowledge
EXPECTED OUTCOMES
The parent or caregiver will
Establish eye, physical, and verbal contact with infant or child.
Demonstrate correct feeding, bathing, and dressing techniques.
State plans to bring the infant or child to clinic for routine physi-
cal and psychological examinations.
Express understanding of developmental norms.
Provide age-related play activities.
Caregiver Emotional Health; Caregiver Physical Health; Knowledge:
Health Resources; Knowledge: Parenting; Parenting Performance;
Role Performance; Social Support
Determine: Assess caregivers psychosocial status, including develop-
mental state, educational level, presence or absence of spouse or sig-
nificant other, financial stressors, previous parenting. Information of
assessment factors helps identify appropriate interventions.
Perform: Act as a role model for parenting when caring for the child
in the presence of the parents. Lack of knowledge of routine child-
care practices, as well as growth and developmental norms, signifi-
cantly contributes to child abuse.
257
Involve patents in the care of the child immediately to promote
attachment to the child.
Inform: Teach caregiver in the basics of infant and childcare.
Research shows that the primary source of information about care
giving is the caregivers own family. If a caregiver lacks an effective
role model, you may need to supply basic information.
Provide written materials on environmental aspects of home main-
tenance. Written materials provide a resource for parents to refer to
when problems arise.
Teach additional skills that enhance coping strategies. Help care-
giver and other family members develop a program using relaxation
strategies such as meditation, guided imagery, yoga, exercise, and so
forth. These strategies reduce stresses associated with parenting.
Teach problem-solving skills.
Attend: Encourage weekly discussions about progress in parenting to
develop family unity and allow members to address problems before
they become overwhelming.
Manage: Assist family members to contact community agencies to
assist in efforts to improve parenting skills, such as self-help groups.
Community resources can lessen familys burden while parents learn
to function independently.
Counseling; Family Integrity Promotion; Family Support; Childbearing
Family; Parenting Promotion; Active Listening; Coping Enhancement
Reference
RISK FOR PERIPHERAL NEUROVASCULAR

DYSFUNCTION
DEFINITION
At risk for disruption in circulation, sensation, or motion of an
extremity
RISK FACTORS
Burns Immobilization
Fractures Orthopedic surgery
Mechanical compression (such Trauma
as tourniquet, cast, brace, Vascular obstruction
dressing, and restraint)
Physical regulation Cardiac function
Sensation/perception Comfort
EXPECTED OUTCOMES
Have no evidence of disability related to peripheral neurovascular
dysfunction after injury or treatment.
Maintain circulation in extremities.
Feel and move each toe or finger after application of cast, brace,
or splint.
Demonstrate correct body positioning techniques.
Express understanding of risk of altered neurovascular status and
need to report symptoms of impaired circulation.
Enroll in smoking-cessation program, as appropriate.
Exhibit no symptoms of neurovascular compromise.
Circulation Status; Neurological Status: Spinal Sensory/Motor Func-
tion; Risk Control; Risk Detection; Tissue Perfusion: Peripheral
Determine: Note if patient will undergo surgery or a procedure that
increases his or her risk of peripheral neurovascular dysfunction to
anticipate complications.
As appropriate, assess circulation before and after application of
the cast, brace, or splint to detect signs of impaired circulation.
Perform: Immobilize the joints directly above and below the
suspected fracture site, leaving room for pulse assessment to facili-
tate monitoring of circulatory status.
Remove the clothing around the suspected fracture site, clean the
site, apply sterile dressings to open wounds, and carefully apply a
cast, brace, or splint to avoid further infection and trauma.
Follow facility guidelines for the application of such devices as
tourniquets, restraints, and tape to ensure adequate circulation in
affected extremity.
259
If you suspect nerve compression, assess the position of the
extremity that has a cast, brace, or splint. Positioning of the extrem-
ity may affect circulation.
Elevate the limb above heart level after surgery or trauma to
reduce the risk of edema. If increased intracompartmental pressure is
evident, maintain the affected limb at heart level to reduce pressure.
If edema appears in the affected extremity, split, bivalve, slit, or
cut a window in the cast and padding according to facility protocol
to avoid neurovascular impairment.
Inject prescribed neurotoxic agents (such as penicillin G,
hydrocortisone, tetanus toxoid, and diazepam) away from the
affected extremity and major nerves to avoid injury.
Avoid flexing the affected extremity. Flexion may reduce venous
circulation, increasing the risk of neurovascular complications.
Administer and monitor the effectiveness of vasodilators, as
ordered, to control vasospasm.
Inform: If patient requires a fasciotomy to restore circulation,
provide educational material that explains this emergency procedure
to reduce patient anxiety.
Instruct patient and family members in proper positioning when
lying in bed and when sitting and in methods of obtaining pressure
relief to avoid pooling of blood and pressure ulcers.
If appropriate, discuss the cause of the injury and safety precau-
tions to avoid further injury.
Instruct patient and family members in recognizing and reporting
symptoms of peripheral neurovascular dysfunction, including numb-
ness, pain, and tingling to prevent onset of neurovascular damage
after discharge.
Attend: If patient smokes, encourage him or her to enroll in a
smoking-cessation program. Quitting smoking may enhance oxygena-
tion, decreasing the risk of peripheral neurovascular dysfunction.
Take measures to ease anxiety which could lead to vasoconstriction.
Manage: Refer patient to appropriate community resources related to
safety precautions to achieve optimal safety level.
Circulatory Precautions; Exercise Promotion: Strength Training; Exercise
Therapy: Joint Mobility; Peripheral Sensation Management; Positioning:
Neurologic; Pressure Ulcer Prevention; Skin Surveillance; Splinting
Reference
Oka, R. K. (2006, SeptemberOctober). Peripheral arterial disease in older
adults: Management of cardiovascular disease risk factors. The Journal of
Cardiovascular Nursing, 21(5, Supp. 1), S15S20.
RISK FOR POISONING

DEFINITION
Accentuated risk of accidental exposure to or ingestion of drugs or
dangerous products in doses sufficient to cause poisoning
RISK FACTORS
Internal Dangerous products or drugs
Cognitive or emotional stored within reach of
difficulties children or confused people
Insufficient resources Flaking or peeling paint or
Lack of drug education plaster in presence of young
Lack of safety precautions children
Occupational setting Poisonous plants
without adequate Storing of large amounts of
safeguards drugs in home
Reduced vision Unprotected contact with
External heavy metals or chemicals
Chemical contamination of Use of illegal drugs contami-
food or water nated with poisonous additives
EXPECTED OUTCOMES
Not ingest or be exposed to dangerous products.
Communicate understanding of need for self-protection.
Explain method for safekeeping of dangerous products.
Risk Control: Drug Use; Risk Detection; Safe Home Environment
Determine: Observe, record, and report falls, seizures, and unsafe
practices to ensure implementation of appropriate interventions.
Overdose of certain medications can cause such neurologic problems
as seizures.
Monitor and record patients respiratory status because certain
poisons can cause respiratory depression.
Monitor and record neurologic status because excessive toxic
exposure can cause coma. Patient may have pinpointed or dilated
pupils, depending on the type of drug ingested and the length of
time patient has been hypoxic.
Monitor vital signs, intake and output, and LOC. Record and
report changes. Severe hypotension may develop following overdose.
It may be related to central nervous system defect, direct myocardial
depression, or vasodilation. Marked hyperthermia can occur with
261
salicylate overdose, which affects metabolic rate. Dehydration may
develop in some patients from an increased respiratory rate, sweat-
ing, vomiting, and urine losses.
Perform: Remove dangerous or potentially dangerous products from
the environment to avoid injury.
Check the settings on oxygen flow meters every hour on patients
known to retain carbon dioxide (e.g., some patients with chronic
obstructive pulmonary disease). This avoids carbon dioxide narcosis
from excessive oxygen therapy in poorly ventilated patients; if
unchecked, patient may stop breathing.
Inform: Provide patient and family members with information about
such specific products as medications, oxygen, and total parenteral
nutrition. Tailor instructions to a specific product and patients abil-
ity to learn self-care. This enables patient and family members to
identify and alter environmental or lifestyle factors to achieve opti-
mum health level.
Attend: Encourage patient to report safety hazards and to incorpo-
rate safe behaviors in the home and work environment to decrease
the chance of poisoning.
Manage: Refer patient to appropriate community resources (police,
fire, and home health agency) for more information to enhance
safety measures.
Home Maintenance Assistance; Medication Management; Risk Iden-
tification; Surveillance: Safety; Environmental Management: Safety;
Environmental Risk Protection
References
Daly, F. F., et al. (2006, May). A risk-assessmentbased approach to the man-
agement of acute poisoning. Emergency Medicine Journal, 23(5), 396399.
Kendall, P. A., et al. (2006, May). Food safety guidance for older adults.
Clinical Infectious Diseases, 42(9), 12981304.
POSTTRAUMA SYNDROME
DEFINITION
Sustained maladaptive response to a traumatic, overwhelming event
Aggression, anxiety, anger, rage
Avoidance, alienation, altered moods
Compulsive behavior
Denial, grief, fear, depression
Detachment
Exaggerated startle response, flashbacks
Guilt
Headaches
Hypervigilance
Intrusive dreams, nightmares, or thoughts; difficulty concentrating
Irritability
Numbness
Panic attacks
Psychogenic amnesia
Repression
Shame
Substance abuse
RELATED FACTORS
Abuse (physical or psycholo- Sudden destruction of home
gical and/or community
Disasters Torture
Epidemics Wars
Serious accident, injury, or Witnessing mutilation or
threat to self or loved one violent death
Emotional Self-perception
EXPECTED OUTCOMES
The patient will
Recover or be rehabilitated from physical injuries to the extent
possible.
State feelings and fears related to traumatic event.
Express feelings of safety.
Use available support systems.
Use effective coping mechanisms to reduce fear.
Maintain or reestablish adaptive social interactions with family
members.
263
Anxiety Self-Control; Body Image; Coping; Depression Level; Fear
Self-Control; Hope; Impulse Self-Control; Quality of Life; Self-
Esteem; Stress Level
Determine: Assess factors in patients culture that may affect his or her
response to trauma; remain supportive and nonjudgmental to show
patient that you support and accept his or her response to trauma.
Perform: Follow medical regimen to manage physical injuries. Attention
to physical needs remains primary, according to Maslows hierarchy.
Inform: Instruct patient in at least one fear-reducing behavior such
as seeking support from others when frightened. As patient learns to
reduce fears, coping skills will increase.
Attend: Provide emotional support:
Visit patient frequently to reduce his or her fear of being alone.
Be available to listen to respond empathetically to patients feelings.
Accept and encourage the statement of patients feelings to reas-
sure patient that feelings are appropriate and valid.
Assure patient of his or her safety, and take the measures
needed to ensure it. Frequent nightmares or flashbacks may cause
patient to question the safety of his or her environment.
Avoid care-related activities or environmental stimuli that may
intensify symptoms associated with trauma (loud noises, bright
lights, abrupt entrances to patients room, or painful procedures or
treatment). Environmental stimuli can easily intensify flashbacks to a
traumatic event.
Reorient patient to surroundings and reality as frequently as nec-
essary. Posttrauma psychic numbing impairs orientation, memory,
and reality perception.
Support patients family members by providing time for them to
express feelings, and helping them understand patients reactions.
This reduces their anxiety and gives them a chance to help patient.
Manage: Offer referrals to other support persons or groups, includ-
ing clergy, mental health professionals, and trauma support groups.
Referrals help patient regain a sense of universality, reduce isolation,
share fears, and deal constructively with feelings.
Active Listening; Anxiety Reduction; Coping Enhancement; Counsel-
ing; Forgiveness Facilitation; Security Enhancement; Socialization
Enhancement; Support Group
Reference
Olszewski, T. M., & Varrasse, J. F. (2005, June). The neurobiology of PTSD:
Implications for nurses. Journal of Psychological Nursing and Mental
Health Services, 43(6), 4047.
RISK FOR POSTTRAUMA SYNDROME

DEFINITION
At risk for sustained maladaptive response to traumatic, overwhelm-
ing event
RISK FACTORS
Diminished ego strength Inadequate social support
Displacement for home Nonsupportive environment
Duration of the event Occupation
Exaggerated sense of responsi- Perception of the event
bility Survivors role in the event
Coping
EXPECTED OUTCOMES
The patient will
Be free from chronic posttrauma response, substance abuse, or
other mental health disorders.
Express understanding of posttrauma response.
Express feelings of safety.
Employ effective coping skills and reach out to appropriate
sources of support to reduce fear.
Coping; Depression Level; Depression Self-Control; Risk Detection;
Social Support; Spiritual Health; Stress Level
Determine: Assess nature of the trauma; losses that occurred from
the traumatic event; effect of the trauma on social interactions;
patients perception of what has occurred; coping responses; mental
status; use of chemicals, for example, alcohol, drugs; available sup-
port systems. Information from assessments factors will help identify
Perform: Structure time to build a trusting relationship with the
patient. The patient will likely talk about fears and be open to ideas
about ways to reduce stress only from someone who is trusted.
Inform: Teach self-healing techniques to both the patient and the
family, such as meditation, guided imagery, yoga, and prayer, to pre-
vent anxiety and aid in keeping patient in a frame of mind to make
positive decisions.
techniques in carrying out usual daily activities in an effort to pre-
vent the development of posttraumatic stress disorder.
265
care. Have patient participate to whatever level possible without
increasing stress level.
Provide patient with concise information about decision-making
skills. This will produce benefits that can reinforce health-seeking
behaviors.
Attend: Listen attentively to patients statements about the power in
caring for himself. Provide encouragement to boost self-confidence of
the patient to encourage a trusting relationship and open discussion.
Reinforce the familys efforts to care for the patient. Let them
Encourage family to support patients independence. Family mem-
bers may be inclined to make decisions and do things to protect the
patient.
Encourage patients cooperation as you continue with healing
techniques, such as therapeutic touch. Some patients may resist
being touched.
Caution patient before you touch him or her. Avoid approaching
patient from behind to avoid actions that may be misinterpreted and
trigger flash back of the traumatic event.
Assist patient to be aware of persons, places, and things that act
as triggers or reduces the traumatic response to encourage active
participation in treatment.
Provide emotional support to the family to be available to answer
questions. Members of the family may have difficulty coping with
the risks the patient faces.
Manage: Schedule time to meet with family and patient to listen to
situation. Refer family to community resources and support groups
Coping Enhancement; Hope Instillation; Mood Management; Self-
Awareness Enhancement
Reference
Guess, K. F. (2006, March). Posttraumatic stress disorder: Early detection is
key. The Nurse Practitioner, 31(3), 2633.
READINESS FOR ENHANCED POWER

DEFINITION
A pattern of participating knowingly in change that is sufficient for
well-being and can be strengthened
Expresses readiness to enhance:
Awareness of possible changes to be made
Freedom to perform changes to be made
Identification of choices that can be made for change
Involvement in creating change
Knowledge for participation in change
Participation in choices for daily living and health
Power
Knowledge
EXPECTED OUTCOMES
The patient will
Express perceived control in influencing health outcomes.
Participate in choices that enhance his or her care and well-being.
Develop a plan for adjusting to significant life changes.
Family Resiliency; Health Beliefs; Perceived Control; Personal Auton-
omy; Psychosocial Adjustment; Life Change
Determine: Assess patients perception of present state of power; per-
ception of ability to enhance power; support systems; patients abil-
ity to identify choices; readiness for change to occur; reliance on the
healthcare system to resolve problems; level of knowledge for posi-
tive decision making. Assessment information will help identify
Perform: Work with the patient to list those areas of health-related
issues in which he or she needs to take greater responsibility and
control. The patient may feel the need to be in greater control with-
out being able to articulate the specifics himself.
List questions in writing that a patient may want to ask his or
her primary caregiver and suggest strategies at further clarifying
information that seems unclear. The patients anxiety may cause him
to forget important point he needs clarified unless he is prepared for
the visit.
267
Teach self-healing techniques to both the patient and the family
usual daily activities. Repeatedly performing these techniques
throughout the day will help further reduce anxiety.
plishments and improvements in his or her condition, no matter how
small they may seem. Give positive feedback. Conversation assists
you to evaluate the patients self-concept and adaptive abilities.
Direct the patients focus beyond the present state.
Manage: Help patient involve the family, community, clergy, and
friends with changes to the care plan to increase the potential of the
patients control over self-care outcomes.
Refer patient and family to other professional caregivers, for
example, dietitian, social worker, clergy, mental health professional.
Support groups such as Ostomy clubs, I Can Cope, and Reach for
Recovery can be helpful to the patient and the family.
Assist patient to utilize appropriate resources by contacting family
and scheduling follow-up appointments. This helps give the patient a
sense of direction and control over his or her future care.
Assertiveness Training; Coping Enhancement; Self-Modification
Assistance; Self-Responsibility Facilitation
Reference
Klam, J., et al. (2006, August). Personal empowerment program: Addressing
health concerns in people with schizophrenia. Journal of Psychosocial Nurs-
ing and Mental Health Services, 44(8), 2028.
POWERLESSNESS
DEFINITION
Perception that ones own action will not significantly affect an out-
come; a perceived lack of control over a current situation or imme-
diate happening
Severe Expressed dissatisfaction over
Apathy inability to perform previous
Depression over physical dete- tasks
rioration Expressed self-doubt regarding
Expressed lack of control over role performance
self-care, current situation, and Failure to monitor progress
outcome Failure to seek information
Deterioration about care
Moderate Low
Anger Expressions of uncertainty
Does not defend self-care about fluctuating energy levels
practices when challenged Passivity
Fear of alienation from care-
givers
RELATED FACTORS
Healthcare environment Interpersonal interaction
Illness-related regimen Lifestyle of helplessness
Knowledge
EXPECTED OUTCOMES
The patient will
Acknowledge fears, feelings, and concerns about current situation.
Make decisions regarding course of treatment.
Decrease level of anxiety by changing response to stressors.
Participate in self-care activities.
Express feeling of regained control.
Accept and adapt to lifestyle changes.
Depression Self-Control; Family Participation in Professional Care;
Health Beliefs; Health Beliefs: Perceived Ability to Perform; Partici-
pation in Healthcare Decisions
Determine: Assess mobility; behavioral responses; coping strategies;
past experiences with illness; knowledge; environment, including
equipment and supplies, healthcare professionals and personnel,
269
lighting, noise, privacy, number and types of stressors; social factors;
spiritual beliefs. Information gained from assessment will help iden-
tify appropriate interventions.
Perform: Work with the patient to identify specific issues in which
the patient feels powerless. Understanding several areas will help the
patient focus on setting goals.
Help the patient develop focused goals. Having goals will give the
patient confidence that his and her efforts will produce results.
Inform: Teach coping strategies to patient and family members. Have
patient practice role-playing to increase the confidence in his or her
ability to handle difficult situation in the healthcare system. Teach
self-healing techniques to both the patient and the family such as
meditation, guided imagery, yoga, and prayer. Teach patient how to
incorporate the use of self-healing techniques in carrying out usual
daily activities. The more routine the use of these techniques
becomes, the greater will be the effectiveness.
Attend: Help patient identify his values, beliefs, hopes, dreams, skills,
and interest. The patients deficits may lie in a lack of self-exploration,
problem-solving methods used, or separation issues with parents.
Promote choices with the most likeliness of success. Specific
instructions can help the patient gain problem-solving ability and
maturity.
Listen to patients personal values and beliefs, but remain
nonjudgmental, even if his or her values and beliefs differ from your
own. Remaining nonjudgmental, but attentive, shows your support.
Explore personal identity issues distressing to the patient to isolate
issues into small, more solvable units.
Accept patients feelings of powerlessness as normal. This indicates
respect for the patient and enhances feelings of self-respect.
Encourage patient to take an active role as a health team member
and in self-care. Active participation will promote self-reliance.
Manage: Organize family conferences to explore potential reactions
to the patients choices, and promote support for the patients inde-
pendent decision making. Meetings can help the patient and family
members ventilate true feelings in a safe environment.
Cognitive Restructuring; Decision-Making Support; Emotional Sup-
port; Health Education; Mood Management; Presence; Self-
Assistance; Self-Responsibility Facilitation; Values Clarification
Reference
Klams, J. (2005, December). Dynamics of hope in adults living with
HIV/AIDS: A substantive theory. Journal of Advanced Nursing, 52(6),
620630.
RISK FOR POWERLESSNESS

DEFINITION
At risk for perceived lack of control over a situation and/or ones
ability to significantly affect an outcome
RISK FACTORS
Psychological Psychological
Absence of integrality Acute injury
Chronic low self-esteem Aging
Deficient knowledge Dying
Disturbed body image Illness
Inadequate coping patterns Progressive debilitating
Lifestyle dependence disease process
Situational low self-esteem
Healthcare system Knowledge
Self-perception Coping
EXPECTED OUTCOMES
The patient will
Make decisions regarding course of action.
Decrease level of anxiety by changing response to stressors.
Participate in self-care activities.
Describe modifications or adjustments to the environment that
allows feelings of control.
Discuss factors in the illness-related regimen over which control
can be maintained.
Demonstrate ability to plan for controllable factors.
Express feeling of maintaining control.
Accept and adapt to lifestyle.
Anxiety Level; Body Image; Coping; Endurance; Information
Processing; Personal Autonomy; Risk Control; Social Support
Determine: Assess for high-risk behaviors; health-promoting activi-
ties; coping skills; activities of daily living, including rest and sleep;
sensory perception; decision-making skills; sexuality patterns. Assess-
ment information helps identify appropriate interventions.
Perform: Modify environment when possible to meet patients self-
care needs to promote sense of control over the environment.
Orient patient to space by walking with patient around space and
assisting him to place personal belongings.
Inform: Teach patient about risk factors and other aspects of the
patients medical condition to help patient feel in control of his or
her care.
271
Attend: Be present when patient is facing situations in which the
patient feels powerlessness to help patient cope.
Encourage patient to express concerns. Set aside time for discus-
sions with the patient about daily events. This helps the patient feel
vaguely understood emotions into focus. Discuss situations that pro-
voke feelings of anxiety, anger, and powerlessness to identify areas
of patient concern and to prevent anger from being inappropriately
directed at self.
Encourage participation in self-care. Provide patient with as many
decisions as possible with regard to self-care (such as positioning,
choosing an injection site, and receiving visitors) to communicate
respect for patient and enhance feelings of independence.
Provide positive environment for patients activities. Encourage
patient to take an active role as a member of his or her healthcare
team. This enhances patients sense of control and reduces passive
and dependent behavior.
Encourage family members to support patient without taking con-
trol to increase patients feelings of self-worth.
Manage: Arrange to accommodate patients spiritual needs. Spiritual
assistance may help patient gain courage and resist despair.
Refer to mental health professional for additional assistance with
coping. Refer patient to community resources that may offer assis-
tance to the patient when needed.
Decision-Making Support; Risk Control; Presence; Self-Assistance
Reference
Kylma, J. (2005, December). Dynamics of hope in adults living with
HIV/AIDS: A substantive theory. Journal of Advanced Nursing, 52(6),
620630.
INEFFECTIVE PROTECTION
DEFINITION
Decrease in the ability to guard self from internal or external threats
such as illness or injury
Altered clotting, anorexia, chilling, cough
Deficient immunity, disorientation
Dyspnea, fatigue, immobility, impaired healing
Insomnia
Itching
Maladaptive stress response, Perspiring
Pressure ulcers
RELATED FACTORS
Abnormal blood files (leukopenia, thrombocytopenia, anemia,
coagulation)
Alcohol abuse
Cancer
Drug therapies (e.g., antineoplastic, corticosteroid, immune, antico-
agulant, thrombolytic)
Extremes of age
Immune disorders
Inadequate nutrition
Cardiac function Physical regulation
Fluids and electrolytes Respiratory function
Pharmacological function Risk management
EXPECTED OUTCOMES
The patient will
Not experience chills, fever, or other signs and symptoms.
Demonstrate use of protective measures, including conservation of
energy, maintenance of balanced diet, and attainment of adequate
rest.
Demonstrate effective coping skills.
Demonstrate personal cleanliness and maintain clean environment.
Maintain safe environment.
Demonstrate increased strength and resistance.
Exhibit improved immune system as evidenced by normal WBC,
CBC and differential, normal sedimentation rate, and immunoelec-
trophoresis.
Express desire for additional health information.
Abuse Protection; Immune Status; Immunization Behavior;
Knowledge: Infection Control; Knowledge: Infection Control
273
Determine: Assess vital signs; high-risk behaviors, knowledge of pres-
ent condition; coping skills; comfort level; activities of daily living;
cardiac, respiratory status, neurologic status; protective mechanisms;
CBC and differential, sedimentation rate, immunoelectrolytes, immu-
noelectrophoresis, blood cultures, wound exudate, sputum, urine.
Assessment information helps identify appropriate interventions.
Perform: Take vital signs every 4 hr. This allows for early detection
of complications.
Administer medications as ordered for symptoms. Discomfort
interferes with rest, interferes with nutritional intake, and places
added stress on the patient.
Inform: Teach protective measures, including the need to conserve
energy, obtain adequate rest, and eat a balanced diet. Adequate sleep
and nutrition enhance immune function. Energy conservation can
help decrease the weakness caused by anemia.
Teach coping strategies, including stress management and
relaxation techniques. Relaxation and decreased stress can increase
function, thereby improving strength and resistance.
Teach patient to guard against falls, cuts, abrasions, and other
types of accidents to prevent infections. Provide written instruction
for the patient so he or she has it to review when needed.
Attend: Promote personal and environmental cleanliness to decrease
threat from microorganisms.
Manage: Order nutritious foods with supplements for the patient.
Encourage him to eat to prevent further complications. Offer to
have dietitian visit patient to assist with this.
If patient has new insights on his own condition or treatment,
encourage him to share this information with his oncologist to fos-
ter a sense of responsibility for obtaining healthcare. Suggest that
patient present practitioner with a summary of his or her findings in
advance of his or her appointment to allow the practitioner time to
review the information.
Coping Enhancement: Environmental; Management: Safety; Infection
Control; Knowledge: Personal Safety Health
Reference
Marrs, J. A. (2006, April). Care of patients with neutropenia. Clinical Journal
of Oncology Nursing, 10(2), 164166.
RAPE-TRAUMA SYNDROME
DEFINITION
Sustained maladaptive response to a forced, violent sexual penetra-
tion against the victims will and consent
Anger, anxiety, and depression Mood swings
Agitation Muscle spasms
Changes in relationships Muscle tension
Confusion Nightmares, sleep
Denial disturbances, and phobias
Dependence Physical trauma
Disorganization Powerlessness
Dissociative disorders Revenge
Embarrassment or shame Sexual dysfunction
Fear or paranoia Shame
Guilt and self-blame Shock
Helplessness Sleep disturbances
Humiliation Substance abuse
Hyperalertness Suicide attempts
Impaired decision making Vulnerability
Loss of self-esteem
Coping
Emotional
Values/beliefs
EXPECTED OUTCOMES
The patient will
Recover from physical injuries to the fullest possible extent.
Express feelings and fears.
Make contact with appropriate sources of support.
Abuse Protection; Abuse Recovery; Emotional Coping
Determine: Assess history of traumatic event; physical injuries
sustained at the time of the trauma; emotional reactions to the
event; support systems available to the patient; coping; problem-
solving strategies. Assessment information will help establish realistic
goals and identify appropriate interventions.
Perform: Explain assessment procedures to the patient to reduce the
level of fear associated with data gathering following a rape.
relaxation efforts usually help promote sleep.
275
Educate patient about various emotional responses to trauma. Rape-
trauma syndrome is a variant of posttraumatic distress disorder.
Responses such as suicidal ideation, disorientation, confusion, extreme
detachment, nightmares, guilt, depression, and flashbacks are common.
The patient may believe that the emotional turmoil she experiences
after rape is abnormal. Pointing out that others have gone through the
same experience may lessen the patients isolation, help her talk about
the symptoms, and motivate her to seek follow-up care.
Teach a variety of techniques that will help the woman cope.
Patient may believe that the emotional turmoil one experiences after
rape is abnormal.
Attend: Provide emotional support. Be available to listen, and accept
the patients feelings to let her know her feelings are valid and
acceptable.
Approach patient in a warm, caring manner to cultivate her trust
and cooperation. Assure patient of her safety, and take all necessary
measures to ensure it.
Manage: Offer referral to other support groups or professionals,
such as clergy, a crisis center, mental health professionals, rape coun-
selors, and Women Organized Against Rape. This will help the
patient express her feelings and develop coping skills.
Abuse Protection Support; Anxiety Reduction; Crisis Intervention;
Rape-Trauma Treatment; Self-Esteem Enhancement
Reference
Boykins, A. D. (2005). The forensic exam: Assessing health characteristics of
adult female victims of recent sexual assault. Journal of Forensic Nursing,
1(4), 166171.
READINESS FOR ENHANCED RELATIONSHIP

DEFINITION
A pattern of mutual partnership that is sufficient to provide each
others needs and can be strengthened
Expresses desire to enhance communication between partners
Expresses satisfaction with sharing of information and ideas
between partners
Expresses satisfaction with fulfilling physical and emotional needs
by ones partner
Demonstrates mutual respect between partners
Meets developmental goals appropriate for family life-cycle stage
Demonstrates well-balanced autonomy and collaboration between
partners
Demonstrates mutual support in daily activities between partners
Identifies each other as a key person
Demonstrates understanding of partners insufficient (physical,
social, and psychological) function
Expresses satisfaction with complementary relation between partners
Sexuality
Emotional
Roles/relationships
EXPECTED OUTCOMES
The patient will
Communicate effectively with partner and family members.
Articulate ways to mutually meet physical and emotional needs of
partner and self.
Participate in appropriate counseling (premarital, preconceptual,
sexual) as needed.
Verbalize that relationships are characterized by well-balanced
autonomy and self-efficacy.
Family Functioning; Role Performance; Sexual Functioning; Social
Interaction Skills
Determine: Assess communication techniques and effectiveness of
couple and family to be able to counsel and/or refer appropriately
as needed.
Perform: Suggest that patient and partner/family members attend
counseling sessions as appropriate for their life-cycle stage. Patients
may need permission from a healthcare professional to feel comfort-
able seeking relationship assistance.
277
Inform: Teach patient and family members normal family life-cycle
stages so that they can better understand what is normal and are
able to anticipate challenges.
Attend: Encourage patient and family members to share information
and ideas in order to enhance their communication.
Manage: Refer as needed to colleagues in other disciplines such as
social workers or counselors to facilitate enhanced communication.
Family Integrity Promotion; Family Support; Preconceptual Counsel-
ing; Sexual Counseling; Socialization Enhancement; Support System
Enhancement
References
Cavanagh, S. (2008). Family structure history and adolescent adjustment.
Journal of Family Issues, 29, 944980.
Prince-Paul, M. (2008). Understanding the meaning of social well-being at the
end of life. Oncology Nursing Forum, 35, 365371.
IMPAIRED RELIGIOSITY
DEFINITION
Impaired ability to exercise reliance in beliefs and/or participate in
rituals of a particular faith tradition
Difficulty adhering to prescribed religious beliefs and rituals (e.g.,
religious ceremonies, dietary regulations, clothing, worship, prayer,
private religious behaviors/reading religious materials/media, holi-
day observances, meetings with religious leaders)
Expresses emotional distress because of separation from faith
community
Expresses a need to reconnect with previous belief patterns
Expresses a need to reconnect with previous religious customs
Questions religious belief patterns
Questions religious customs
RELATED FACTORS
Aging Ineffective coping
End-stage life crises Ineffective support
Life transitions Lack of security
Illness Cultural barriers to practicing
Pain religion
Anxiety Spiritual crises
Fear of death Suffering
Values/beliefs
EXPECTED OUTCOMES
The patient will
Describe conflicts with his or her religious beliefs and the effects
of his or her illness on these beliefs.
Accept counsel of a person trained in spirituality.
Engage in religious practices to the extent that it is therapeutic.
Begin differentiating between delusional thinking and reality ABG
levels.
Hope; Motivation; Quality of Life; Spiritual Health
Determine: Assess spiritual or religious beliefs; religious affiliation;
importance of religion in daily life; religious involvement of family;
religious dietary restrictions; importance of religion in helping with
usual coping. Assessment information helps identify appropriate
interventions.
Attend: Approach patient in a nonjudgmental way when he or she is
discussing religious beliefs or spiritual needs. The nurses beliefs may
279
differ radically but it is a professional responsibility to assist the
patient in an ethically sensitive way.
Help patient list the religious practices most important to him or
her to determine what is possible to provide in the hospital.
Acquire simple-to-obtain items, such as books, picturse, CD,
cross, to provide comfort to the patient.
Confirm that patients spiritual needs are being satisfied so that
modifications can be made in the plan.
Involve family members in helping meet patients spiritual needs if
the patient agrees. If family members have strong spiritual beliefs,
they can be a help to one another in times of pain and difficulty.
Encourage patient and family to express feelings associated with
diagnosis, treatment, and recovery. Expression of feelings helps
patient and family cope with treatment.
Schedule time to spend with the family. They need time with
healthcare providers to ask questions.
Manage: Suggest a referral to a clergy person or faith community
nurse so that the person can discuss deeper spiritual issues.
AcidBase Management; Bedside Laboratory Testing; Active Listen-
ing; Spiritual Growth; Spiritual Support
Reference
Elipoulos, E. (2005, Fall). Belief as the foundation for health. Health Ministry
Journal, 1(3), 513.
READINESS FOR ENHANCED RELIGIOSITY

DEFINITION
Ability to increase reliance on religious beliefs and/or participate in
rituals of a particular faith tradition
Expresses desire to strengthen religious belief patterns that had
provided comfort in the past
Expresses desire to strengthen religious belief patterns that had
provided religion in the past
Expresses desire to strengthen religious customs that had provided
religion in the past
Questions belief patterns that are harmful
Rejects customs that are harmful
Rejects assistance expanding religious options
Requests forgiveness
Requests reconciliation
Requests meetings with religious leaders
Requests religious experiences
Knowledge
EXPECTED OUTCOMES
The parents will
Articulate what gives him or her strength and hope.
Discuss aspects of religion that are important to work with the
patient to establish a trusting relationship.
Perform if the patient is to talk about spiritual needs, it must be
in a nonjudgmental, warm, caring environment.
List how staff can facilitate his or her participation in religious
practices.
Request or agree to talk to a religious professional.
Express a feeling of peace with provided religious opportunities.
Health Beliefs; Hope; Motivation; Quality of Life; Spiritual Health
Determine: Assess support system; involvement in religion; religious
affiliation; religious practices and/or spiritual practices that are
meaningful to the patient; perceptions of faith, life, death, and suf-
fering. Information from assessment helps identify appropriate inter-
ventions.
Perform: Obtain for the patient objects of religious significance that
he requests, for example, a cross, a copy of the Bible or Koran, a
281
menorah. Patients often find comfort in having religious objects at
the bedside.
Attend: Listen attentively to the patient. Do not argue about the
patients beliefs or perceptions of faith. Ask for clarification when it
is needed. Honest communication is important to gain the patients
trust.
Offer to provide whatever things can easily be found to support
the patients spiritual needs, such as reading material, pictures,
music, and so forth. This may promote comfort.
Explore with the patient to what extent he wishes to incorporate
his religious beliefs into his daily life. This would introduce the idea
of making a plan to enhance religiosity.
Help patient list the religious practices that are most important to
him to comfort him while planning much more complex support.
Manage: Evaluate to what extent the patient perceives that his or
her spiritual needs are being met. This way modifications can be
made if indicated.
Arrange a referral to a member of the clergy or person designated
by the patient as a spiritual guide so the patient may discuss deeper
spiritual issues.
SUGGESTED NIC OUTCOMES
Presence; Religious Ritual Enhancement; Spiritual Growth Facilita-
tion; Spiritual Support; Values Clarification
Reference
Mattison, P. (2006). Assessing spiritual health. Health Ministry Journal, 2(2),
513.
RISK FOR IMPAIRED RELIGIOSITY

DEFINITION
At risk for an impaired ability to exercise reliance on religious
beliefs and/or participate in rituals of a particular faith tradition
RISK FACTORS
Cultural or environmental barriers
Illness or hospitalization
Ineffective support/coping systems
Lack of social interaction
Lack of transportation
Life transitions
EXPECTED OUTCOMES
The caregiver will
Establish eye, physical, and verbal contact with the infant or child.
Demonstrate correct feeding, bathing, feeding, and dressing tech-
niques.
State plans to bring the infant or child to clinic for routine physi-
cal and psychological examinations.
Express understanding of developmental norms.
Provide age-related play activities.
Caregiver Performance: Direct Care; Family Coping; Family
Functioning; Parenting Performance
Determine: Assess religious affiliation; degree of active participation
in religious activities; support/coping systems; social interaction;
present living circumstances. Assessment information helps identify
Inform: Teach patient about the resources that are available to him
or her as a preparation for developing a realistic plan. The plan will
be more meaningful to the patient if he or she has already lined up
possible resources.
Attend: Encourage patient to talk about the religious practices that are
important to him or her to provide focus for appropriate interventions.
Help patient explore modifications to his or her activities without
compromising spiritual comfort. Decision making promotes feelings
of independence and control.
Have patient list options for participation in religious activities to
promote optimism or acceptance in present situations.
283
Manage: Involve family, friends, and clergy to provide appropriate
spiritual support.
Check daily or weekly with the patient to evaluate the effective-
ness of the patients plan.
Active Listening; Emotional Support; Hope Instillation; Presence;
Religious Ritual Enhancement; Spiritual Growth Facilitation; Spiri-
tual Support; Values Clarification
Reference
Epipoulos, E. (2005, Fall). Belief as the foundation for health. Journal of
Health Ministry, 1(3), 513.
RELOCATION STRESS SYNDROME

DEFINITION
Physiological and/or psychosocial disturbance following transfer
from one environment to another
Alienation Increased verbalized needs or
Anger unwillingness to move
Anxiety related to separation Insecurity
Concern over relocation Loneliness
Dependency Loss of identity or self-worth
Depression Pessimism
Fear Sleep disturbance
Frustration Withdrawal
Increased physical symptoms Worry
or illness
RELATED FACTORS
Decreased health status Move from one environment
Feelings of powerlessness to another
Impaired psychosocial health Language barrier
Isolation from familiar Losses
locations and persons Passive coping
Lack of adequate support sys- Unpredictability of
tem or predeparture counsel- experience
ing or social support
ASSESSMENT FOCUS (Refer to comprehensive assessment parameter.)
Knowledge
EXPECTED OUTCOMES
The patient will
Request information about new environment.
Communicate understanding of relocation.
Take steps to prepare for relocation.
Use available resources.
Express satisfaction with adjustment to new environment.
Loneliness Severity; Psychosocial Adjustment: Life Change; Quality
of Life; Stress Level
Determine: Assess patients needs for additional healthcare services
before relocation to ensure receipt of appropriate care in the new
environment.
285
Perform: Assign a primary nurse to patient to provide a consistent,
caring, and accepting environment that enhances patients
adjustment and well-being.
Help patient and family members prepare for relocation. Conduct
group discussions, provide pictures of the new setting, and commu-
nicate any additional information that will ease transition to help
patient cope with a new environment.
If possible, allow patient and family members to visit the new
location, and provide introductions to the new staff. The more
familiar the environment, the less stress patient will experience dur-
ing relocation.
Inform: Educate family members about relocation stress syndrome
and its potential effects to encourage family members to provide
needed emotional support throughout the transition period.
Attend: Encourage patient to express emotions associated with relo-
cation to provide opportunity to correct misconceptions, answer
questions, and reduce anxiety.
Reassure patient that family members and friends know his or her
new location and will continue to visit to reduce feelings of
abandonment and anxiety.
Manage: Communicate all aspects of patients discharge plan to
appropriate staff members at the new location to ensure continuity
of care.
Active Listening; Coping Enhancement; Self-Responsibility Facilitation
Reference
Beard, H. (2005, NovemberDecember). Does intermediate care minimize relo-
cation stress for patients leaving the ICU? Nursing in Critical Care, 10(6),
272278.
RISK FOR RELOCATION STRESS SYNDROME

DEFINITION
At risk for physiological and/or psychosocial disturbance following
transfer from one environment to another
RISK FACTORS
Decreased health status Moderate mental competence
Feelings of powerlessness Move from one environment
Lack of adequate support sys- to another
tem or group Passive coping
Lack of predeparture counseling Past, current, or recent losses
Moderate to high degree of Unpredictability of experiences
environmental change
Knowledge
EXPECTED OUTCOMES
The patient will
Request information about the new environment.
Participate in decision making regarding relocation.
Communicate understanding of need for relocation.
Express satisfaction with adjustment to new environment.
Take steps to prepare for relocation along with family members or
partner.
Loneliness Severity; Psychosocial Adjustment: Life Change; Quality
of Life; Stress Level
Determine: Assess patients needs for additional healthcare services
before relocation to ensure that patient receives appropriate care in
the new environment.
Perform: Assign a primary nurse to patient to provide a consistent,
caring, and accepting environment that enhances patients
adjustment and well-being.
If possible, include patient in the decision-making process regard-
ing potential location, dates, and circumstances of relocation to pro-
mote a feeling of participation in choices, which will allow feeling
of control.
If possible, allow patient and family members to visit the new
location, and provide introductions to the new staff. The more
familiar the environment, the less stress patient will experience dur-
ing relocation.
287
Inform: Educate family members about relocation stress syndrome
and its potential effects to encourage family members to provide
needed emotional support throughout the transition period.
Attend: Help patient and family members prepare for relocation.
Conduct group discussions, provide pictures of setting, and commu-
nicate any information that will ease transition to help patient with
the new environment.
Encourage patient to express emotions associated with relocation
or provide an opportunity to correct misconceptions and answer
questions. This helps reduce anxiety about relocation.
Manage: Communicate all aspects of patients discharge plan to
appropriate staff members at the new location to ensure continuity
of care.
Reassure patient that family members and friends know his or her
new location and will continue to visit to reduce feelings of
abandonment.
Active Listening; Coping Enhancement; Self-Responsibility Facilitation
Reference
Beard, H. (2005, NovemberDecember). Does intermediate care minimize relo-
cation stress for patients leaving the ICU? Nursing in Critical Care, 10(6),
272278.
IMPAIRED INDIVIDUAL RESILIENCE

DEFINITION
Decreased ability to sustain a pattern of positive responses to an
adverse situation or crisis
Maladaptive coping responses Increased autonomic activity
Poor impulse control Perceived inability to cope
Substance abuse Psychological disorganization
Depression Apathy
Anxiety Fear of inability to cope
RELATED FACTORS
Incomplete pyschosocial development
Lack of resources
Impaired communication
Lack of support systems
Support systems Safety
Substance use Decision making
Self-care Anxiety
Depression Spiritual needs
EXPECTED OUTCOMES
The patient will
Remain free from harming self or others.
Avoid abusing substances.
Identify personal strengths.
Engage in activities that promote health.
Identify strategies that have been successful in previous times of
stress.
Role Performance; Effective/Enhanced Resilience; Knowledge: Health
Behavior
Determine: Explore with patients what maladaptive behaviors they
are exhibiting because of impaired individual resilience. The patient
must take ownership of behaviors before change can occur.
Monitor responses to change to assess their effect on patient.
Perform: Assist patient in making a list of strengths and resources
with contact information and the parameters for contacting those
resources. Planning for needs decreases anxiety and increases self-care.
Inform: Instruct patient to engage in positive health behaviors. Ade-
quate sleep, nutritional intake, and activity improve decision making.
Attend: Encourage patient to wait to make life-changing decisions
until the current crisis is over. Decision making is impaired during
times of crisis.
289
Manage: Refer patients to mental health resources in the event of
maladaptive coping or safety risk. Individuals with impaired individ-
ual resilience face an increased risk of physical and mental illness.
Anxiety Reduction; Coping Enhancement; Decision-Making Support;
Spiritual Support
Reference
Townsend, M. C. (2008). Nursing diagnosis in psychiatric nursing. Philadel-
phia: F. A. Davis.
RISK FOR COMPROMISED RESILIENCE

DEFINITION
At risk for decreased ability to sustain a pattern of positive
responses to an adverse situation or crisis
Recent significant loss
Recent actual or perceived threat
Verbalized concern about ability to handle situation
Unfamiliarity with current feelings
Worry
Increased autonomic activity
Uncertainty of what to do
Psychological disorganization
Multiple stressors
Fear of inability to cope
RISK FACTORS
Lack of experience with current situation
Impaired coping related to grief
Perceptions of self-efficacy
Support systems Physical regulation
Comfort Decision making
Self-care Coping
Autonomic system Spiritual needs
EXPECTED OUTCOMES
The patient will
Identify available support systems to maintain resilience.
Identify healthy coping strategies.
Verbalize belief in self to withstand current situation.
Engage in activities that promote health.
Identify strategies that have been successful in previous times of
stress.
Role Performance; Effective/Enhanced Resilience; Knowledge: Health
Behavior
Determine: Evaluate previous mechanisms of effective coping in diffi-
cult situations. Assimilating current situation to previous successes
enhances resilience.
Perform: Assist patient in making a list of strengths and resources.
Be knowledgeable of cultural aspects of resilience. Cultural relevance
is critical to all aspects of patient care.
291
Inform: Instruct patient to engage in positive self-talk: I can handle
this, I will accomplish one thing today and celebrate it. A posi-
tive outlook increases endorphins and enhances self-efficacy.
Attend: Encourage patient to maintain activities of health promotion
including adequate sleep, nutritious eating, and activity. Maintaining
adequate self-care enhances resilience.
Manage: Refer patients to mental health resources in the event of
maladaptive coping or safety risk. Risk of compromised resilience
may lead to actual compromised resilience.
Anxiety Reduction; Coping Enhancement; Decision-Making Support;
Spiritual Support
Reference
Fortinash, K. M., & Holoday-Worret, P. D. (2007). Psychiatric nursing care
plans. St. Louis, MO: Mosby.
READINESS FOR ENHANCED RESILIENCE

DEFINITION
A pattern of positive responses to an adverse situation or crisis that
can be strengthened to optimize human potential
Expressed desire to enhance resilience
Presence of crisis
Effective use of conflict management strategies
Increases positive relationships with others
Identifies support systems
Identifies available resources
Sets goals
Makes progress toward goals
Enhances personal coping skills
Takes responsibility for actions
Involvement in activities
Enhanced sense of control
Effective use of communication skills
Demonstrates positive outlook
Verbalizes self-esteem
Access to resources
RELATED FACTORS
Expected developmental Effective meaningful
conflicts resolved communication
Available resources Presence of support systems
Thought process
Perception of self
Stability of relationships
EXPECTED OUTCOMES
The patient will
Acknowledge readiness for increased resilience.
Verbalize the feeling of resilience.
Identify impact of resilience toward growth.
Enhanced Self-Esteem; Enhanced Personal Potential; Knowledge:
Health Behavior
Determine: Explore with patients their process and growth in mas-
tering a situation or crisis that enhanced their resilience. Mastery of
responses in crisis situations can generalize to future situations.
Monitor attainment of goals to assess need for further
intervention.
293
Perform: Listen therapeutically to patients self-exploration and mas-
tery. Active listening is the key to the therapeutic alliance and accu-
rate assessment.
Demonstrate conflict resolution principles through role playing to
be able to practice in a controlled environment.
Inform: Instruct the patient to journal experiences for future reflec-
tion. Journaling is a therapeutic tool for self-exploration and expan-
sion.
Attend: Guide patient to review life goals that might now be attain-
able. Personal potential is maximized in an environment of
resilience.
Manage: Encourage patient to assist others or get involved to enrich
the lives of others. Humans benefit from shared positive experiences.
Coping Enhancement; Enhanced Human Potential
Reference
Townsend, M. C. (2008). Nursing diagnosis in psychiatric nursing. Philadel-
phia: F. A. Davis.
INEFFECTIVE ROLE PERFORMANCE

DEFINITION
Patterns of behavior and self-expression that do not match the envi-
ronmental context, norms, and exceptions
Anxiety related to role performance, or altered role perceptions
Change in capacity to resume role, perception of role (by self and
others), or usual responsibilities
Conflict among vocational, family, cultural, and social roles
Discrimination
Domestic violence or harassment
Inadequate adaptation to change or transition
Inadequate self-management, motivation, confidence, competence,
or coping skills for fulfilling role
Inappropriate developmental expectations
Lack of external support or opportunities for enacting role
Lack of knowledge about roles and responsibilities
Pessimism
Powerlessness
Role ambivalence, denial, conflict, confusion, dissatisfaction, over-
load, or strain
RELATED FACTORS
Knowledge (e.g., inadequate role model)
Physiological (e.g., depression, cognitive deficits)
Social (e.g., domestic violence, lack of resources)
Coping Knowledge
EXPECTED OUTCOMES
Express feelings about diminished ability to perform usual roles.
Recognize and state feelings about limitations imposed by illness.
Make decisions about course of treatment and management of illness.
Continue to function in usual roles as much as possible.
Express feelings of making productive contribution to self-care, to
others, or to environment.
Caregiver Lifestyle Disruption; Psychosocial Adjustment: Life
Change; Role Performance
Determine: Assess patients knowledge of illness to establish baseline
data.
Perform: If possible, assign the same nurse to patient each shift to
establish rapport and foster development of a therapeutic relationship.
295
Spend ample time with patient each shift to foster a sense of
safety and decrease loneliness. If possible, assign the same nurse to
patient each shift to establish rapport and promote a therapeutic
relationship.
Encourage patient to express thoughts and feelings to identify life
affects of altered role performance.
Express belief in ability of patient to develop coping skills to help
patient gain confidence.
Be aware of patients emotional vulnerability, and allow open
expression of all emotions. An accepting attitude will help patient
deal with the effects of chronic illness and loss of functioning.
Provide opportunities for patient to make decisions. Showing
respect for patients decision-making ability enhances feelings of
independence.
Inform: Educate patient and family members about redefining roles
to promote optimal functioning. Through education, family members
may become resources in patients care.
Offer patient and family members a realistic assessment of
patients illness, and communicate hope for the immediate future.
Education helps promote patient safety and security and helps fam-
ily members plan for future healthcare requirements.
Attend: Encourage patient to participate in self-care activities, keep-
ing in mind his or her physical and emotional limitations. Involve-
ment in self-care promotes optimal functioning.
Help patient recognize and use personal strengths to maintain
optimal functioning and promote a healthy self-image.
Encourage patient to continue to fulfill life roles within the con-
straints posed by illness. This will help patient maintain a sense of
purpose and preserve connections with other people.
Encourage patient to participate in his or her care as an active
member of the healthcare team. This will help establish mutually
accepted goals between patient and his or her caregivers. Patient
who participates in care is more likely to take an active role in
other aspects of life.
Manage: Help family members identify their feelings about patients
decreased role functioning. Encourage participation in a support
group. Relatives of patient may need social support, information,
and an outlet for ventilating feelings.
Caregiver Support; Family Process Maintenance; Role Enhancement
Reference
Emslie, C. (2005, August). Women, men and coronary heart disease: A review
of the qualitative literature. Journal of Advanced Nursing, 51(4), 382395.
READINESS FOR ENHANCED SELF-CARE

DEFINITION
A pattern of performing activities for oneself that helps to meet
health-related goals and can be strengthened
Expresses desire to enhance independence in maintaining life
Expresses desire to enhance independence in maintaining health
Expresses desire to enhance independence in maintaining personal
development
Expresses desire to enhance independence in maintaining well-being
Expresses desire to enhance knowledge of responsibility and strate-
gies for self-care
Behavior Emotional
Coping Self-care
EXPECTED OUTCOMES
The patient will
Demonstrate positive decision making toward maximizing poten-
tial for self-care.
Express satisfaction with independence in assuming responsibility
for planning self-care.
Involve staff, family, and community in developing strategies for
self-care.
Seek out health-related information as needed.
Monitor self-care measures taken for effectiveness and make alter-
ations as needed.
Adherence Behavior; Client Satisfaction: Functional Assistance;
Health Beliefs: Perceived Ability to Perform
Determine: Assess patients satisfaction with level of self-care to sup-
port general well-being.
Assess current ability to provide self-care to establish a baseline.
Assess effectiveness of self-care measures to identify the need for
adjustments.
Perform: Assist patient to develop plan to promote autonomous deci-
sion making to increase patients responsibility for facilitating care.
Inform: Provide information that supports implementation of a pro-
gram to sustain health-seeking behavior to promote patient
autonomy in self-care.
Attend: Encourage health team, family, and community efforts to
participate in patients self-care initiatives to promote satisfactory
mutual goal-setting and group efforts.
297
Encourage patient and his or her family to participate in support
networks that promote patient independence, where possible, to pro-
mote patient and family resilience.
Manage: Develop a referral list for community resources to promote
patients enhanced self-care.
Mutual Goal-Setting; Resiliency Promotion; Self-Responsibility
Facilitation
Reference
Moser, A., et al. (2007, February). Patient autonomy in nurse-led shared care:
A review of theoretical and empirical literature. Journal of Advanced Nurs-
ing, 57(4), 357365.
BATHING/HYGIENE SELF-CARE DEFICIT

DEFINITION
Impaired ability to perform or complete bathing/hygiene activities
for oneself
Inability to dry body
Inability to get into and out of bathroom
Inability to obtain bath supplies
Inability to obtain or get water source
Inability to regulate water temperature or flow
Inability to wash body or body parts
RELATED FACTORS
Cognitive impairment Musculoskeletal, perceptual, and/
Decreased motivation or neuromuscular impairment
Environmental barriers Pain
Inability to perceive body Severe anxiety
part Weakness
EXPECTED OUTCOMES
The patient will
Have self-care needs met.
Communicate feelings about limitations.
Demonstrate correct use of assistive devices.
Carry out bathing and hygiene program daily.
Self-Care: ADLs; Self-Care: Bathing; Self-Care: Hygiene; Self-Care:
Oral Hygiene
Determine: Observe patients functional level every shift; document
and report any changes. Careful observation helps you adjust nurs-
ing actions to meet patients needs.
Monitor the completion of bathing and hygiene daily. Praise
patients accomplishments. Reinforcement and rewards may encour-
age renewed effort.
Perform: Perform the prescribed treatment for underlying
musculoskeletal impairment. Monitor patients progress, reporting
favorable and adverse responses to treatment. Applying therapy con-
sistently aids patients independence.
299
Provide assistive devices, such as a long-handled toothbrush, for
bathing and hygiene; instruct patient on use. Appropriate assistive
devices encourage independence.
Assist with or perform bathing and hygiene daily. Assist only
when patient has difficulty to promote feeling of independence.
Inform: Instruct patient and family members in bathing and hygiene
techniques (you can give family members written instructions). Have
patient and family members demonstrate bathing and hygiene under
supervision. Return demonstration identifies problem areas and
increases patients and family members self-confidence.
Attend: Encourage patient to voice feelings and concerns about self-
care deficits to help patient achieve the highest functional level pos-
sible.
Manage: As needed, refer patient to a psychiatric liaison nurse, sup-
port group, or home health care agency. These extra resources will
reinforce activities planned to meet patients needs.
Bathing; Ear Care; Foot Care; Hair Care; Nail Care; Self-Care Assis-
tance
Reference
Polzien, G. (2006, JulyAugust). Care after hip replacement. Home Healthcare
Nurse, 24(7), 420422.
DRESSING/GROOMING SELF-CARE DEFICIT

DEFINITION
Impaired ability to perform or complete dressing and grooming
activities for self
Inability to choose clothing
Inability to put clothing on upper and/or lower body
Inability to maintain appearance at a satisfactory level
Inability to pick up clothing
Inability to put on shoes, socks, or other items of clothing
Inability to remove clothes
Inability to use assistive devices
RELATED FACTORS
Inability to perceive Severe anxiety
body part Weakness
EXPECTED OUTCOMES
The patient will
Demonstrate the correct use of assistive devices.
Carry out dressing and grooming program daily.
Self-Care: ADLs; Self-Care: Dressing
Monitor patients abilities to dress and groom daily. This identifies
problem areas before they become sources of frustration.
Perform: Perform the prescribed treatment for underlying
Provide enough time for patient to perform dressing and groom-
ing. Rushing creates unnecessary stress and promotes failure.
301
Provide necessary assistive devices, such as a long-handled
shoehorn and zipper pull, as needed. Instruct patient on use. Appro-
priate assistive devices encourage independence.
Assist with or perform dressing and grooming: fasten clothes,
comb hair, and clean nails. Provide help only when patient has diffi-
culty to promote feeling of independence.
Inform: Instruct patient and family members in dressing and groom-
ing techniques (you can give family members written instructions).
Have patient and family members demonstrate dressing and groom-
ing techniques under supervision. Return demonstration reveals
problem areas and increases self-confidence.
Attend: Encourage patient to voice feelings and concerns about
self-care deficits to help patient achieve the highest functional level
possible.
Encourage family members to provide clothing patient can easily
manage. Patient may benefit from clothing slightly larger than regu-
lar size and Velcro straps. Such clothing makes independent dressing
easier.
port group, or home healthcare agency. These extra resources will
Hair Care; Self-Care Assistance: Dressing/Grooming
Reference
Suzuki, M., et al. (2006, November). Predicting recovery of upper-body dress-
ing ability after stroke. Archives of Physical Medicine and Rehabilitation,
87(11), 14961502.
FEEDING SELF-CARE DEFICIT

DEFINITION
Impaired ability to perform or complete feeding activities
Inability to perform one or more of the following:
Bring food from receptacle to mouth
Chew food
Complete meals
Get food onto utensil
Handle a cup or glass
Handle utensils
Ingest food safely and in a socially acceptable manner
Ingest sufficient food
Open containers
Prepare food
Swallow food
Use assistive devices
RELATED FACTORS
Environmental Pain
barriers Severe anxiety
Fatigue Weakness
EXPECTED OUTCOMES
The patient will
Express feelings about feeding limitations.
Maintain weight at ___ lb.
Have no evidence of aspiration.
Consume ___ % of diet.
Carry out feeding program daily.
Nutritional Status; Self-Care: ADLs; Self-Care: Eating; Swallowing
Status
Monitor and record breath sounds every 4 hr to check for aspira-
tion of food. Report crackles, wheezes, or rhonchi.
303
Perform: Perform the prescribed treatment of underlying
Weigh patient weekly and record his or her weight. Report a change
of more than 1 lb/week to ensure adequate nutrition and fluid balance.
Initiate an ordered feeding program:
Determine the types of food best handled by patient to encour-
age patients feelings of independence.
Place patient in high Fowlers position to feed to aid swallowing
and digestion. Support weakened extremities, and wash patients
face and hands before meals to promote a sense of well-being
and safety.
Provide assistive devices such as plate guard, rocker knife to
allow more independence; instruct patient on their use to pro-
mote independence.
Supervise or assist at each meal, for example, cut food into
small pieces. This aids chewing, swallowing, and digestion, and
reduces the risk of choking or aspiration.
Feed patient slowly. Rushing causes stress, reducing digestive
activity and causing intestinal spasms.
Keep suction equipment at the bedside to remove aspirated
foods if necessary.
Record the percentage of food consumed to ensure adequate
nutrition.
Inform: Instruct patient and family members in feeding techniques
and equipment. This aids understanding and encourages compliance.
Return demonstration reveals problem areas and increases self-
confidence.
Attend: Encourage patient to express feelings and concerns about
feeding deficits to help patient achieve the highest functional level.
Encourage patient to carry out the aspects of feeding according to
his or her abilities. This gives patient a sense of achievement and
control.
Manage: Refer patient to a psychiatric liaison nurse, support group,
or community agencies such as Visiting Nurse Association and
Meals On Wheels. Additional resources reinforce activities planned
to meet patients needs.
Fluid Management; Nutrition Management; Nutritional Monitoring;
Self-Care Assistance: Feeding; Swallowing Therapy
Reference
Westergren, A. (2006, June). Detection of eating difficulties after stroke: A sys-
tematic review. International Nursing Review, 53(2), 143149.
TOILETING SELF-CARE DEFICIT

DEFINITION
Impaired ability to perform or complete own toileting activities
Inability to carry out proper toilet hygiene
Inability to flush toilet or empty commode
Inability to get to toilet or commode
Inability to manipulate clothing for toileting
Inability to sit on or rise from toilet or commode
RELATED FACTORS
Fatigue Severe anxiety
Impaired transfer ability Weakness
EXPECTED OUTCOMES
The patient will
Maintain continence.
Carry out toileting program daily.
Self-Care: ADLs; Self-Care: Hygiene; Self-Care: Toileting
Monitor intake and output and skin condition; record episodes of
incontinence. Accurate intake and output records can identify poten-
tial imbalances.
Perform: Perform the prescribed treatment of underlying
Use assistive devices, as needed, such as an external catheter at
night, a bedpan or urinal every 2 hr during the day, and adaptive
equipment for bowel care. Instruct on use. As control improves,
305
reduce the use of assistive devices. Assisting at an appropriate level
helps maintain patients self-esteem.
Assist with toileting only if needed. Allow patient to perform
independently as much as possible to promote independence.
Perform urinary and bowel care if needed. Follow urinary or
bowel elimination plans. Monitoring success or failure of toileting
plans helps identify and resolve problem areas.
Inform: Instruct patient and family members in toileting routine (you
can give family members written instructions). Have patient and
family members demonstrate toileting routine under supervision.
Return demonstration identifies problem areas and increases patients
self-confidence.
Attend: Encourage patient to voice feelings and concerns about his
or her self-care deficits to help patient achieve the highest functional
level possible.
port group, or home healthcare agency. Additional resources
Bowel Training; Self-Care Assistance: Toileting; Urinary Elimination
Management
Reference
Polzien, G. (2006, JulyAugust). Care after hip replacement. Home Healthcare
Nurse, 24(7), 420422.
READINESS FOR ENHANCED SELF-CONCEPT

DEFINITION
A pattern of perceptions or ideas about self that is sufficient for
well-being and can be strengthened
Accepts strengths and limitations
Actions are congruent with expressed feelings and thoughts
Expresses confidence in abilities
Expresses satisfaction with thoughts about self, sense of
worthiness, role performance, body image, and personal identity
Expresses willingness to enhance self-concept
Growth and development Values/beliefs
EXPECTED OUTCOMES
The patient will
Articulate long- and short-term goals.
Express motivation necessary to achieve goals.
Develop realistic plan to achieve stated goals.
Practice self-management strategies needed to be successful.
Evaluate progress and modify behavior as needed.
Body Image; Neglect Recovery; Personal Autonomy; Self-Esteem
Determine: Assess patients satisfaction with level of self-concept to
support general well-being.
Perform: Provide patient with materials and resources on health-
related issues that affect her attitude. Knowledge will enhance
patients motivation or resolve.
Have patient list one or two realistic, practical behaviors that will
facilitate achieving goals. The more positive her behaviors are, the
greater the chance patient has of being successful.
Inform: Answer questions related to written material so patient is
adequately prepared to establish realistic goals.
Attend: Assist patient in writing long- and short-term goals. These
goals can serve as tools for self-evaluation as new behaviors are
being practiced.
Assist patient to determine positive rewards for successful behav-
ior changes. Reinforcers are needed for new behavior to continue.
Manage: Develop a referral list for community resources to promote
patients enhanced self-concept.
307
Hope Instillation; Self-Awareness Enhancement; Self-Responsibility
Facilitation
Reference
Schulman-Green, D. J., et al. (2006, October). Goal setting as a shared deci-
sion making strategy among clinicians and their older patients. Patient Edu-
cation and Counseling, 63(1/2), 145151.
CHRONIC LOW SELF-ESTEEM

DEFINITION
Long-standing negative self-evaluation/feelings about self or self-
capabilities
Dependent on others opinions
Evaluation of self as unable to deal with events
Exaggerates negative feedback about self
Excessively seeks assurance
Expressions of shame
Hesitant to try new situations
Rejects positive feedback about self
RELATED FACTORS
Lack of affection Repeated failures
Lack of approval Repeated negative reinforcement
Perceived lack of belonging Traumatic event
Behavior Role/responsibilities
Emotional
EXPECTED OUTCOMES
The patient will
Voice feelings related to current situation and its effect on self-esteem.
Report feeling safe in agency environment.
Make a verbal contract not to harm self while in the facility.
Gradually join in self-care and decision-making process.
Decrease number of negative self-defeating comments.
Accept positive and negative feedback without exaggeration.
Body Image; Depression Level; Mood Equilibrium; Motivation;
Personal Autonomy; Quality of Life; Self-Esteem
Determine: Assess reason for hospitalization; perception of self; and
cognitive ability. Information gained from the assessment will assist to
identify appropriate goals and interventions.
Perform: Provide for a specific amount of uninterrupted time each
day to engage the patient in conversation. This will allow the
patient time for self-exploration, which promotes future change.
When appropriate, institute suicide precaution according to proto-
col. Patient needs supervision until he or she demonstrates adequate
self-control to ensure his or her own safety.
Provide the patient with a simple structured daily routine. Struc-
tured activity limits the patients anxious behavior.
309
Encourage discussion of problems patient considers important.
Have patient make a list of three most critical issues. This creates
opportunity for patient to identify problems and begin setting realis-
tic goals to build self-confidence.
Encourage bathing, grooming, and other hygiene functions for the
patient everyday, as needed. Encourage patient to do as much as
possible for himself or herself. Greater independence will help
strengthen self-esteem.
Inform: Teach self-healing techniques to patient and family such as
meditation, guided imagery, yoga and prayer to prevent anxiety and
encourage a positive frame of mind.
skills to produce benefits that can reinforce health-seeking behaviors.
Attend: Provide patient with positive feedback for verbal reports or
behaviors that indicate a return to positive self-appraisal. This gives
patient feelings of significance, approval, and competence, which can
help cope effectively with stressful situations.
Encourage social interaction. Disturbed interpersonal relationships
may be an outward expression of self-hate.
Be available to answer any questions patient's family may have to
provide accurate information and emotional support.
Manage: Assist patient to seek assistance when discharged in order to
help replace maladaptive coping behaviors with more adaptive ones.
Schedule time to meet with family and patient to listen to ways in
which they plan to enhance their coping skills in the present situa-
tion. This better ensures success in meeting established goals.
Refer family to community resources and support groups avail-
able to assist in managing patients illness and providing emotional
and financial assistance to caregivers.
Active Listening; Body Image Enhancement; Coping Enhancement;
Decision-Making Support; Hope Instillation; Self-Esteem
Enhancement; Support Group
Reference
Captain, C. (2006, August). Is your patient a suicidal risk? Nursing, 36(8),
4347.
SITUATIONAL LOW SELF-ESTEEM

DEFINITION
Development of a negative perception of self-worth in response to a
current situation (specify)
Evaluation of self as being unable to deal with situations or events
Expressions of helplessness or uselessness
Indecisive or nonassertive behavior
Self-negating verbalizations
Verbally reports current situational challenge to self-worth
RELATED FACTORS
Behavior inconsistent with Disturbed body image
values Failures, rejections, or loss
Changes in development or Functional impairment
social role changes Lack of recognition
Behavior Role/responsibilities
Emotional
EXPECTED OUTCOMES
The patient will
Voice feelings related to current situation and its effect on self-
esteem.
Verbally appraise self before and during current health problems.
Participate in decisions related to care and therapies.
Report a sense of control over life events.
Articulate return to previous positive feelings about self.
Decision Making; Grief Resolution; Psychosocial Adjustment: Life
Change; Self-Esteem
Determine: Assess health history, including mental status (affect, gen-
eral appearance, and mood) and cognitive ability; as well as
unhealthy coping and environmental factors. Information gained
from the assessment will assist to identify appropriate interventions.
Perform: Spend time alone with patient listening to the problems
that are important to him or her at this time. Have patient make a
list of the three most critical issues he or she has now to help
patient identify his or her strengths and begin setting some realistic
goals to build his or her self-confidence.
Encourage bathing, grooming, and other hygiene functions for the
311
possible for himself or herself. Greater independence will help
strengthen self-esteem.
such as meditation, guided imagery, yoga, and prayer to prevent
anxiety and aid in keeping patient in a frame of mind to make posi-
tive decisions.
skills. This will produce benefits that can reinforce health-seeking
behaviors.
Attend: Encourage patient to express feelings about self (past and
present). Self-exploration encourages patient to consider future
change.
Provide patient with positive feedback for verbal reports or behav-
iors that indicate a return to positive self-appraisal. This gives
help cope effectively with stressful situations.
Provide a specific amount of noncore time to engage patient in
conversation. Such discussions help patient assume responsibility for
coping responses.
Reinforce the familys efforts to care for the patient and support
patients independence. Let them know they are doing well in order
to ease adaptation to new caregiver roles. Provide emotional support
to family by being available to answer questions. Accurate informa-
tion will help family cope with current situation.
Manage: Schedule time to meet with family and patient to listen to
situation. Helping patient and/or family develop a realistic plan will
better ensure success in meeting established goals.
Refer family to community resources and support groups available
to assist in managing patients illness and providing emotional and
Anticipatory Guidance; Decision-Making support; Grief Work Facili-
tation; Self-Esteem Enhancement
Reference
Raty, L., & Gustafasson, B. (2006, February). Emotions in relation to health-
care encounters affecting self-esteem. The Journal of Neuroscience Nursing,
38(1), 4250.
RISK FOR SITUATIONAL LOW SELF-ESTEEM

DEFINITION
Risk for developing negative perception of self-worth in response to
a current situation (specify)
RISK FACTOR
Behavior inconsistent with Functional impairment
values History of abandonment,
Decreased control over envi- abuse, neglect, or learned
ronment helplessness
Change in developmental or Lack of recognition
social role changes Physical illness
Disturbed body image Unrealistic self-expectations
Failures, rejections, or loss
Behavior
Coping
Emotional
EXPECTED OUTCOMES
The patient will
Participate in decisions related to care and therapy.
Maintain eye contact and initiate conversation.
Maintain an open and upright posture.
Verbally assess feelings about current situation and health problems
and impact on lifestyle.
Express positive feelings about self (verbally or through behaviors),
indicating acceptance of changes caused by health problems or
situation.
Perform hygiene and self-care activities indicating attention
to appearance.
Express interest in talking to others who have successfully
overcome the problem of low self-esteem.
Self-Esteem; Life Changes; Decision Making; Perceived Control;
Psychosocial Adjustment
Determine: Assess developmental stage; family system; role in family;
sibling position; health history; mental status, including affect, gen-
eral appearance, mood; cognitive ability; support systems; patients
ability to identify choices; readiness for change to occur; level of
knowledge for positive decision making, coping mechanisms,
environmental factors. Information from assessment will assist the
nurse to identify appropriate interventions.
Perform: Encourage bathing, grooming, and other hygiene functions
for the patient everyday, as needed. Encourage patient to do as
313
much as possible for himself or herself. Greater independence will
help strengthen self-esteem.
Teach self-healing techniques to both the patient and family such
as meditation, guided imagery, yoga, and prayer. Teach patient how
to incorporate the use of self-healing techniques in carrying out
usual daily activities. These techniques help calm the mind and pro-
mote ability to cooperate with the difficulties associated with low
self-esteem.
plishments and about improvements in condition no matter how
small these may seem. Give positive feedback. Conversation assists
you to evaluate the patients self-concept and adaptive abilities.
Direct the patients focus beyond the present state. As long as a
patient focuses only on the present state, he or she will have
difficulty planning activities that will move him or her forward.
example, dietitian, social worker, clergy, and mental health
professional. Support groups such as Ostomy clubs, I Can Cope,
and Reach for Recovery can provide physical, material, financial,
and emotional resources to patient and the family during the recov-
ery period.
and scheduling follow-up appointments. This helps give the patient a
sense of direction and control over his or her future care.
Assertiveness Training; Coping Enhancement; Self-Modification
Assistance; Self-Responsibility Facilitation
Reference
Klam, J., et al. (2006, August). Personal empowerment program: Addressing
health concerns in people with schizophrenia. Journal of Psychosocial Nurs-
ing and Mental Health Services, 44(8), 2028.
INEFFECTIVE SELF-HEALTH MANAGEMENT

DEFINITION
Pattern of regulating and integrating into daily living a therapeutic
regimen for treatment of illness and its sequelae that is unsatisfactory
for meeting specific health goals
Failure to include treatment regimens in daily living
Failure to take action to reduce risk factors
Makes choices in daily living ineffective for meeting health goals
Verbalizes desire to manage the illness
Verbalizes difficulty with prescribed regimen
RELATED FACTORS
Complexity of healthcare sys- Inadequate number of cues to
tem and therapeutic regimen action
Decisional conflicts Knowledge deficit
Economic difficulties Mistrust of regimen
Excessive demands made (e.g., Powerlessness
individual, family) Perceived: barriers, seriousness,
Family conflict and patterns of susceptibility, and benefits
healthcare Social support deficit
Self-care
Behavior
Knowledge
EXPECTED OUTCOMES
The patient will
Acknowledge responsibility to manage own health condition.
Identify any barriers to optimal self-health management and deter-
mine plan to address them.
Refine problem-solving skills over time.
Increase self-efficacy, the confidence that one can carry out a
behavior necessary to reach a desired goal.
Health Status; Adherence Behavior; Compliance Behavior; Decision
Making; Health Orientation; Health-Promoting Behavior; Personal
Health Status
Determine: Monitor patients self-efficacy and use of problem-solving
skills as patient manages own health. These concepts reflect a new
paradigm in health management that acknowledges that patients
need many skills and confidence to carry out plan of care.
Perform: Assist patient in setting goals and making informed
choices. This patientnurse collaborative relationship helps patient
315
and nurse identify barriers to optimal health management and
overcome them.
Inform: Teach patients about their disease states and regimens but,
more importantly, teach patients problem-solving skills to ensure
that they actively participate in their self-health management despite
any setbacks that they might experience.
Attend: Provide encouragement to help motivate patient to maximize
healthy behaviors. This highlights that behavior is best changed by
internal motivation rather than by external motivation.
Manage: Coordinate with social services and colleagues in other dis-
ciplines to ensure that family, economic, and social barriers to opti-
mal self-health management have been addressed.
Beahvior Modification; Complex Relationship Building; Decision-
Making Support; Health Education; Learning Facilitation; Mutual
Goal-Setting; Self-Awareness Enhancement
References
Byth, F. M., March, L. M., Nicholas, M. K., & Cousins, M. J. (2005). Self-
management of chronic pain: a population-based study. Pain, 113, 285292.
Grey, M., Knafl, K., & McCorkle, R. (2006). A framework for the study of
self- and family management of chronic conditions. Nursing Outlook, 54,
278286.
SELF-MUTILATION
DEFINITION
Deliberate self-injurious behavior causing tissue damage with the
intent of causing nonfatal injury to attain relief of tension
Abrading Inhalation of harmful stance
Biting Insertion of object into body
Constricting a body part part
Cuts on a body part Picking at wounds
Hitting Scratches on body
Ingestion of harmful Self-inflicted burns
substances Severing
RELATED FACTORS
Adolescence Dissociation
Autistic individual Disturbed body image
Battered child History of inability to plan
Borderline personality disorder solutions
Character disorder Impulsivity
Coping Roles/responsibilities
Emotional
EXPECTED OUTCOMES
The patient will
Refrain from harming self while in the hospital.
Express an increased sense of security.
Report being able to cope better with disorganization, aggressive
impulses, anxiety, and hallucinations.
Verbalize absence of or fewer dissociative states.
Participate in therapeutic milieu.
Describe community resources that can provide assistance when
she feels out of control.
Impulse Self-Control; Risk Control; Self-Mutilation Restraint
Determine: Assess behavioral responses; coping strategies; number and
types of stressors; social factors; and spiritual beliefs. Assessment
information will assist in identifying appropriate goal and interven-
tions.
Perform: Move patient to a quiet room to reduce stimuli if he or she
is in a dissociative state. Remove all dangerous objects from patients
room to prevent injury. Place patient under observation to provide
protection and increase his or her sense of security.
317
Administer psychotropic medications, as prescribed, to reduce ten-
sion, impulse behavior, hallucinations, and panic.
Inform: Teach patients coping strategies to family members. Family
members and friends can help patient practice adaptive methods of
coping with self-destructive feelings.
Have patient and family members practice role-playing to increase
the confidence in the patients ability to handle difficult situations.
Teach self-healing techniques to both patient and family such as
meditation, guided imagery, yoga, and prayer. Teach patient how to
daily activities. These techniques can reduce the anxiety that comes
from attempting to cope with his or her disease.
Teach additional skills that enhance coping and relaxation strate-
gies for the patient and family (i.e., meditation, guided imagery,
yoga, exercise). Self-healing gives the patient a better sense of con-
trol over regaining independence.
Attend: Limit the number of staff who interact with patient to provide
continuity of care and enhance a sense of security.
If patient is participating in a therapeutic milieu, discuss his or
her risk of self-harm with community members to provide patient
with enhanced protection and psychological support.
If patient causes harm to self, provide care in a calm, nonjudge-
mental manner. Encourage discussion of feelings that caused self-
mutilation to help patient connect self-destructive behavior to feel-
ings that preceded it, and provide an opportunity to explore
alternative ways of dealing with negative feelings.
Accept patients feelings of powerlessness as normal. This indicates
respect for the patient and enhances feelings of self-respect.
Encourage patient to take an active role in self-care to promote a
sense of control.
Manage: Organize frequent staff meetings to ensure patient care is
consistent with current behavior.
Organize family conferences to allow opportunities for the family
to discuss their particular frustrations and hopes in relation to the
patients current situation. Family conferences can help the patient
and family members ventilate true feelings in a safe environment.
Area Restriction; Self-Harm; Environmental Management; Impulse
Control; Coping Behaviors
Reference
McDonald, C. (2006, August). Self-mutilation in adolescents. The Journal of
School Nursing, 22(4), 193200.
RISK FOR SELF-MUTILATION

DEFINITION
At risk for deliberate self-injurious behavior causing tissue damage
with the intent of causing nonfatal injury to attain relief of tension
RISK FACTORS
Adolescence Low self-esteem
Autistic individuals Loss of significant relationship
Battered child Peers who self-mutilate
Character disorders Perfectionism
Disturbed body image Substance abuse
Isolation from peers Violence between parental
Living in a nontraditional figures
setting
Behavior Self-perception
Emotional
EXPECTED OUTCOMES
The patient will
Refrain from harming self.
Express increased feelings of security.
Report improved ability to cope with self-destructive feelings.
Experience no episodes of dissociation.
Participate in therapeutic milieu.
Report suicidal ideations to staff.
Abuse Recovery Status; Anxiety Level; Impulse Self-Control; Risk
Control; Self-Mutilation Restraint
Determine: Assess high-risk behaviors; health-promoting activities;
coping skills; ADLs, including rest and sleep; sensory perception;
decision-making skills; and sexuality patterns. Information from the
assessment will help establish outcomes to be developed.
Perform: Administer psychotropic medications, as prescribed, to
reduce tension, impulsive behavior, hallucinations, and panic.
Remove all dangerous objects from the environment to enhance
security.
Move patient to a quiet room to reduce stimuli if he or she is in
a dissociative state.
Place patient under observation to provide protection and increase
patients sense of security.
Inform: Teach patient about risk factors and other aspects of patients
medical condition to help patient feel in control of his or her care.
319
Teach patients coping strategies to family members so they can
help patient practice adaptive methods of coping with self-destruc-
tive feelings.
Teach self-healing techniques to both the patient and family such
as meditation, guided imagery, yoga, and prayer. These techniques
can reduce the anxiety that comes from attempting to cope with his
or her disease.
Attend: Make short-term verbal contracts with patient in which the
patient states he will not harm himself. This makes patient aware
that he is ultimately responsible for his own safety and he can guar-
antee it.
Ask patient directly whether he is thinking about suicide and if
so, what plan he has. A self-destructive patient may become suicidal
and may require additional precautions.
If patient harms himself or herself, care for him or her in a calm,
nonjudgmental manner. Encourage patient to talk about feelings that
prompted the self-mutilation. Discussion of the event may help the
patient connect self-destructive behavior to feelings that preceded
it. Discussion may also provide him or her with an opportunity
to explore alternative ways of dealing with negative thoughts and
feelings.
Manage: Organize frequent staff meetings to ensure consistency in
managing the patients care that is consistent with his current behavior.
Organize family conferences to allow opportunities for the family
to discuss their particular frustrations and hopes in relation to the
patients current situation. Family conferences can help the patient
and family members ventilate true feelings in a safe environment.
Area Restriction; Self-Harm; Environmental Management; Impulse
Control; Coping Behaviors
Reference
McDonald, C. (2006, August). Self-mutilation in adolescents. The Journal of
School Nursing, 22(4), 193200.
SELF-NEGLECT
DEFINITION
A constellation of culturally framed behaviors involving one or more
self-care activities in which there is a failure to maintain a socially
accepted standard of health and well-being
Inadequate personal hygiene
Inadequate environmental hygiene
Nonadherence to health activities
RELATED FACTORS
Cognitive impairment Functional impairment
Depression Lifestyle/choice
Learning disability Malingering
Fear of institutionalization Substance abuse
Frontal lobe dysfunction and Major life stressory (e.g.,
executive processing ability coping difficulty)
Self-care Behavior
EXPECTED OUTCOMES
The patient will
Demonstrate improved cognitive, functional, and mental health
status.
Adhere to prescribed health activities.
Experience increased safety.
Demonstrate improved coping with complex health circumstances
including personal and environmental hygiene, nutrition, and
fitness.
Have fewer acute hospitalizations and emergency room visits.
Adherence Behavior; Compliance Behavior; Decision Making; Health
Orientation; Motivation; Personal Well-Being; Risk Control; Self-
Care Status
Determine: Assess patient with complex health issues for adequate
coping abilities because poor coping skills may lead to unintentional
self-neglect.
Assess patient with failing self-care for changes in cognitive func-
tion because neglected self-care may be the first noticable sign of
diminishing cognitive function.
Perform: Involve patients family in care activities as appropriate to
improve the chance that the patient will incorporate recommended
regimens into lifestyle as long-term choice.
321
Inform: Teach strategies to enhance adherence to medication and
other health regimens. Some instances of self-neglect occur because
the patient has not been able to incorporate recommended regimens
into his or her lifestyle.
Attend: Encourage patient to identify internally motivating factors
for adhering to health regimens. Persons who intentionally neglect
self-care as a lifestyle choice (i.e., fail to comply with medication
and treatment regimens) will fare better if the decision to improve
self-care is theirs.
Manage: Refer patient demonstrating a significant decline in self-care
abilities (i.e., posing a threat to self and/or community) for compe-
tency evaluation because unintentional self-neglect may indicate
diminished competency.
Behavior Management; Counseling; Exercise Promotion; Limit Set-
ting; Mutual Goal-Setting; Self-Care Assistance; Self-Responsibility
Facilitation; Weight Management
References
Gibbons, S., Lauder, W., & Ludwick, R. (2006). Self-neglect: A proposed new
NANDA diagnosis. International Journal of Nursing Terminologies and
Classifications, 17, 1018.
McDermott, S. (2008). The devil is in the details: Self-neglect in Australia.
Journal of Elder Abuse and Neglect, 20, 231250.
DISTURBED SENSORY PERCEPTION

DEFINITION
Change in the amount or patterning of incoming stimuli accompa-
nied by a diminished, exaggerated, distorted, or impaired response
to such stimuli
Change in behavior pattern, problem-solving abilities, sensory acuity,
and/or usual response to stimuli
Disorientation
Hallucinations
Irritability
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
Altered sensory integration, Electrolyte imbalance
reception, and/or transmission Excessive environmental stimuli
Biochemical imbalance Psychological stress
Activity/exercise Risk management
Neurocognition Sensory/perception
EXPECTED OUTCOMES
Use adaptive equipment (such as glasses and hearing aid), as needed.
Remain oriented to time, place, and person.
Remain safe in environment.
Respond to environmental stimuli.
Communicate understanding of sensory stimulation exercises.
Take an active role in preventing sensory deprivation and
isolation.
Communication: Receptive; Hearing Compensation Behavior;
Sensory Function: Taste & Smell
Determine: Assess need for and encourage patient to use glasses, a
hearing aid, or other adaptive devices to help reduce sensory
deprivation.
Perform: Reorient patient to reality:
Call patient by name.
Tell patient your name.
Give background information (time, place, and date) frequently
throughout the day.
323
Orient to the environment, including sights and sounds.
Use large signs as visual cues.
Post a photo of patient on the door if the patient is ambulatory
and disoriented.
Provide visual contrast in the environment.
These measures help reduce patients sensory deprivation.
Arrange the environment to offset deficit:
Place patient in a room that allows his or her a full view of the
environment.
Encourage family to bring in personal articles, such as books,
cards, and photos.
Keep articles in the same place to promote a sense of identity.
Use such safety precautions as a nightlight, when needed.
These measures reduce sensory deprivation.
Turn on the television and radio for short periods of time based
on patients interests to help orient patient to reality.
Inform: Communicate patients response level to family members and
staff; record on the care plan and update, as needed. Patients
response to stimuli allows evaluation of his or her sensory depriva-
tion level.
Attend: Talk to patient while providing care; encourage family mem-
bers to discuss past and present events with patient. Verbal stimuli
can improve patients reality orientation.
Arrange to be with patient at predetermined times during the day
to prevent feelings of isolation.
Hold patients hand when talking. Discuss interests with patient
and family members. Obtain needed items such as talking books.
Sensory stimuli help reduce patients sensory deprivation.
Manage: Assist patient and family members in planning short trips
outside the facility or healthcare environment. Educate patient about
mobility, toileting, feeding, suctioning, and other requirements. Leav-
ing the facility or healthcare environment helps reduce patients sen-
sory deprivation and promote mental acuity.
Cognitive Stimulation; Environmental Management
Reference
Mauk, K. L. (2006, February). Reaching and teaching older adults. Nursing,
36(2), 17.
DISTURBED SENSORY PERCEPTION:

AUDITORY
DEFINITION
nied by a diminished exaggerated, distorted, or impaired response to
such stimuli
Change in behavior pattern, problem-solving abilities, sensory
acuity, and/or usual response to stimuli
Disorientation
Hallucinations
Irritability
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
EXPECTED OUTCOMES
The patient will
Discuss impact of hearing loss on lifestyle.
Remain oriented to time, place, and person.
Express feeling of comfort and security.
Show interest in external environment.
Compensate for auditory loss by using signing, gestures,
lip-reading, hearing aid, or other measures.
Plan to use community resources to assist with auditory deficit.
Cognitive Orientation; Communication: Receptive; Hearing Compen-
sation Behavior
Determine: Determine how to communicate effectively with patient,
using gestures, written words, signing, or lip-reading. If patient has
a hearing aid, encourage its use. Planned communication with
patient improves care delivery.
Perform: Allow patient to express feelings about hearing loss.
Convey willingness to listen, but dont pressure patient to talk. Giv-
ing patient a chance to talk about hearing loss enhances acceptance
of loss.
325
Give patient clear, concise explanations of treatments and proce-
dures, avoiding information overload. Face patient when speaking;
enunciate words clearly, slowly, and in a normal speaking voice; and
avoid putting your hands to your mouth when speaking. Patient will
be better able to join in his or her care with a better understanding
of the treatment plan.
Provide sensory stimulation by using tactile and visual stimuli to
help compensate for hearing loss. Encourage family members to
bring familiar objects from home. Sensory stimulation of patients
other senses helps compensate for hearing loss.
Provide reality orientation if patient is confused or disoriented to
permit more effective patientstaff interaction.
Make sure that other staff members are aware of patients hearing
deficit. Record information on patients care plan and chart cover to
ensure effective nursing care delivery by all staff members.
Inform: Teach patient alternative ways to cope with hearing loss;
care of hearing aid if prescribed; and safety and protective measures
to avoid harm or injury (such as an amplifier or signal devices on
telephone and visual cues in environment). A knowledgeable patient
can better cope with hearing loss.
Attend: Respond to the call bell by going to patients room as soon
as possible. If feasible, assign the same staff members to care for
patient. These measures provide continuity of care and reduce
patients fears.
Manage: Refer patient to appropriate community resources, such as
Self-help for Hard of Hearing People, to help patient adapt to loss.
Involve family members in planning and encourage their participa-
tion. These measures help patient and family cope better with hear-
ing loss.
Cognitive Stimulation; Communication Enhancement: Hearing
Deficit; Environmental Management
Reference
Wallhagen, M. I., et al. (2006, October). Sensory impairment in older adults:
Part 1: Hearing loss. American Journal of Nursing, 106(10), 4048.

GUSTATORY
DEFINITION
such stimuli
Altered taste sense; complete loss of taste (ageusia); distorted sense
of taste (dysgeusia); partial loss of taste (hypogeusia)
Change in behavior pattern, problem-solving abilities, sensory
acuity, and/or usual response to stimuli
Disorientation
Hallucinations
Irritability
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
EXPECTED OUTCOMES
The patient will
Report changes in sense of taste.
Identify ways to enhance enjoyment of food.
Consume ___ % of diet.
Maintain weight.
Appetite; Cognitive Orientation; Nutritional Status: Food & Fluid
Intake; Sensory Function: Taste & Smell; Stress Level
Determine: Assess changes in sense of taste to establish baseline.
Gently raise patients tongue slightly with a gauze sponge. Use
moistened applicator to place a few crystals of salt or sugar on
one side of the tongue. Wipe the tongue clean and ask patient to
identify the taste sensation to test sweet and salt taste sensation.
Apply a tiny amount of quinine to the base of the tongue to
test bitter taste sensation.
Place a small piece of sour pickle on patients tongue to test
sour taste sensation.
327
Pinch off one nostril and ask patient to close his or her eyes and
sniff through the open nostril to identify nonirritating odors, such as
coffee, lime, and wintergreen, to evaluate sense of smell; much of
what constitutes taste is actually smell. Repeat the test on the oppo-
site nostril.
Monitor and record patients weight each week to detect signs of
weight loss.
Perform: Modify patients diet so he or she can distinguish and enjoy
as many tastes as possible.
Inform: Identify ways to emphasize smell and enhance the flavor of
food, such as using herbs and spices, to compensate for loss of
taste.
Attend: Serve food in attractive surroundings. Prepare meals in an
inviting manner, using various different-colored foods, to appeal to
patients visual sense.
Manage: Refer patient to appropriate resources, such as nutritionist,
to help patient adapt to loss.
Involve family members in planning, and encourage their partici-
pation. These measures help patient and family cope better with
gustatory loss.
Electrolyte Management; Environmental Management; Feeding; Fluid
Management; Neurologic Monitoring; Nutritional Monitoring
Reference
Ravasco, P. (2005). Aspects of taste and compliance in patients with cancer.
European Journal of Oncology Nursing, 9(Suppl. 2), S84S91.

KINESTHETIC
DEFINITION
nied by a diminished, exaggerated, distorted, or impaired response
to such stimuli
Diminished motor coordination
Disorientation
Hallucinations
Inability to identify position or location of body parts
Inability to perceive changes in angles of joints
Irritability
Muscular weakness, flaccidity, rigidity, or atrophy
Paralysis
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
EXPECTED OUTCOMES
The patient will
Express feelings associated with changes in kinesthetic perception.
Implement safety precautions.
Have no skin breakdown, especially in areas around vulnerable
joints.
Participate in self-care activities to maximum ability.
Participate in appropriate exercise program.
Not experience injury.
Balance; Body Positioning: Self-Initiated; Sensory Function: Proprio-
ception
Determine: Assess changes in motor coordination, paralysis, or mus-
cular weakness, and report observations to healthcare team to
ensure appropriate care.
329
Inspect patients skin daily, especially areas around vulnerable
joints, to detect signs of skin breakdown.
Perform: Implement appropriate safety measures, such as installing
padded bed rails, maintaining bed in low position, and using wheel-
chair lapboard, to avoid patient injury.
Encourage use of a letter board, electric wheelchair, and feeding
and dressing devices to promote independence.
Inform: Remind patient (and teach staff members to remind patient)
of the need to check the positioning of hands and feet to ensure
safety and avoid injury. Emphasize importance of communicating a
supportive and accepting attitude to enhance patients emotional
well-being.
Attend: Encourage patient to express feelings related to diminished
kinesthetic perception to promote acceptance of perceptual impair-
ment.
Manage: Refer patient to appropriate resources, such as physical
therapist who can provide patient with an exercise program that
includes active and passive ROM routines to maintain ROM and
prevent musculoskeletal degeneration.
Energy Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance; Progressive Muscle Relaxation
Reference
Bunting-Perry, L. K. (2006, April). Palliative care in Parkinsons disease: Impli-
cations for neuroscience nursing. Journal of Neuroscience Nursing, 38(2),
106113.

OLFACTORY
DEFINITION
such stimuli
Altered sense of smell: diminished (hyposmia) or absent (anosmia)
Diminished sense of taste and loss of appetite
Disorientation
Hallucinations
Irritability
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
EXPECTED OUTCOMES
The patient will
Express understanding that decreased olfactory perception is
temporary.
Report improvements in olfactory perception.
Maintain weight.
Describe how to identify noxious odors and maintain safe home
environment.
Cognitive Orientation; Nutritional Status: Food & Fluid Intake;
Sensory Function: Taste & Smell
Determine: Assess patients ability to smell and document findings to
establish baseline.
Weigh patient weekly to detect weight loss and monitor for possi-
ble malnutrition.
Monitor laboratory values and vital signs to detect signs of infection.
Perform: Prepare foods the patient likes and serve them in an inviting
manner to stimulate patients appetite.
331
Use various different-colored foods with each meal to appeal to
patients visual sense.
Administer prescribed medications, such as antihistamines and
nose drops or sprays, to relieve nasal congestion.
Record nasal drainage characteristics, including amount, color,
consistency, and odor, to assess for changes in olfactory condition.
Ensure adequate hydration, and provide for humidification in
patients room to prevent drying of mucous membranes.
If altered olfactory perception doesnt result from simple nasal
congestion, prepare patient for diagnostic tests, such as sinus transil-
lumination, skull x-ray, and computed tomography scan, as ordered,
to guide further treatment.
Inform: Educate patient to place smoke detectors throughout his or
her home to signal danger of fire and to discard food according to
dates on packages rather than relying on his or her sense of smell to
avoid eating spoiled food.
Tell patient with nasal packing that his or her sense of smell will
return after packing is removed and swelling decreases to provide
reassurance.
Attend: If altered olfactory perception results from nasal congestion,
reassure patient that the condition is temporary and his or her sense
of smell should return to diminish anxiety.
Manage: Refer patient to appropriate resources such as utility com-
pany to implement measures for protecting against possible gas
leaks.
Cognitive Stimulation; Environmental Management; Nutrition Man-
agement
Reference
Vance, D., & Burrage, J. (2006, July). Chemosensory declines in older adults
with HIV: Identifying interventions. Journal of Gerontological Nursing,
32(7), 4248.
DISTURBED SENSORY PERCEPTION: TACTILE

DEFINITION
such stimuli
Altered sense of touch: abnormal sensation, such as numbness,
prickling, and tingling (paresthesia); decreased sensitivity to stimu-
lation (hypoesthesia); diminished sensitivity to pain (hypalgesia);
impaired sense of touch (dysesthesia)
Disorientation
Hallucinations
Irritability
Poor concentration
Restlessness
Sensory distortions
RELATED FACTORS
EXPECTED OUTCOMES
Express feelings about changes in tactile perception.
Experience no falls or injury.
Experience no skin breakdown.
Describe safety measures to avoid injury.
Describe a program to provide increased tactile stimulation.
Ambulation; Balance; Body Mechanics Performance; Body Position-
ing: Self-Initiated; Coordinated Movement; Neurological Status:
Spinal Sensory/Motor Function; Sensory Function: Cutaneous
Determine: Inspect patients skin daily, especially on her feet, to
detect signs of skin breakdown.
Perform: Use padded side rails or a lapboard on the wheelchair, if
appropriate. Make any other environmental modifications, as needed,
to promote safe tactile experiences and prevent accidental injury.
333
Inform: Teach patient to regularly check placement of her hands and
feet to avoid injury.
Teach patient safety measures, such as testing bath water with a
thermometer, to prevent injury.
Teach family members or caregiver to touch patient in areas with
preserved sensation, using various textures, to promote sensory
input. For example, suggest family members to provide a satin pil-
lowcase, wrap a soft scarf around patients neck, or give a gentle
massage with scented lotion.
Attend: Allow patient to express feelings associated with altered tac-
tile perception. Be willing to listen, but dont pressure patient to
talk. Providing a chance to talk will help patient cope with sensory
deficits.
Manage: Refer patient to appropriate resources such as utility com-
pany to reduce water temperature to protect patient from injury.
Activity Therapy; Environmental Management: Safety; Fluid
Management; Fluid Monitoring; Neurologic Monitoring; Nutrition
Management; Peripheral Sensation Management; Pressure Manage-
ment; Skin Surveillance
Reference
Crimlisk, J. T., & Grande, M. M. (2004, JanuaryFebruary). Neurologic
assessment skills for the acute medical surgical nurse. Orthopedic Nursing,
23(1), 39.
DISTURBED SENSORY PERCEPTION: VISUAL

DEFINITION
such stimuli
Change in behavior pattern, Impaired communication
problem-solving abilities, sen- Irritability
sory acuity, and/or usual Poor concentration
response to stimuli Restlessness
Hallucinations Sensory/visual distortion
RELATED FACTORS
Altered sensory integration, Excessive environmental
reception, and/or transmission stimuli
Biochemical and/or electrolyte Psychological stress
imbalance
EXPECTED OUTCOMES
The patient will
Express feelings of safety, comfort, and security.
Maintain orientation to time, place, and person.
Regain visual functioning and come to terms with any vision loss.
State plans to use appropriate resources and adaptive devices.
Body Image; Distorted Thought Self-Control; Risk Control; Sensory
Function: Vision; Vision Compensation Behavior
Determine: Inspect patients skin daily, especially on his or her feet,
to detect signs of skin breakdown.
Perform: Remove excess furniture/equipment from patients room,
and orient patient to the room to reduce risk for injury.
Permit patient who is blind on admission to direct arrangement of
the room. Accompany patient to the bathroom until s/he is familiar
with the room. Make arrangements for seeing-eye dog, if needed.
These measures foster patient's level of independence.
Determine best angle to approach patient with hemianopia.
Encourage patient to scan the room for visual cues, and place
objects within visual field to help patient meet self-care needs.
For patient with diplopia, patch one eye to ameliorate double
vision. Provide sensory stimulation by using tactile, auditory, and gus-
tatory stimuli to help compensate for vision loss. Obtain large-print
335
books, talking books, audiotapes, or radio, as preferred by patient.
Nonvisual sensory stimulation helps patient adjust to vision loss.
If patient has had eye surgery, provide appropriate care, as indi-
cated. Be aware of and take steps to limit activities that increase
intraocular pressure, such as bending, stooping, getting on and off
the bedpan, coughing, and vomiting. Avoiding postoperative activi-
ties that increase intraocular pressure helps reduce complications.
Administer medications, monitor patient and report any adverse
effects to reduce pain and control the disease process.
Inform: Give patient clear, concise explanations of treatments and
procedures. Enunciate words clearly, slowly, and in a normal speak-
ing voice. A knowledgeable patient will be better able to participate
in the treatment plan.
Educate patient in alternative ways of coping with vision loss;
care of such adaptive devices as eyeglasses, magnifying glass, contact
lenses, and artificial eye; and administration of eyedrops, including
name, dosage, and therapeutic and adverse effects. A knowledgeable
patient will be better able to cope with vision loss.
Attend: Allow patient to express feelings about vision loss and con-
vey willingness to listen, but dont pressure patient to talk. Allowing
patient to voice fears aids acceptance of vision loss.
Always introduce yourself or announce your presence upon entering
patients room; let patient know when youre leaving. Familiarizing
patient with the caregiver aids reality orientation and conveys respect.
Encourage family and friends to visit patient and bring familiar
objects to aid in reality orientation.
Respond to the call bell as soon as possible. Assign the same staff
members to care for patient if possible. These measures help reduce
patients fears and provide continuity of care.
Manage: Refer patient and his or her family to the American Founda-
tion for the Blind or other community agencies or support groups.
Postdischarge support will help patient and family cope better with
patients vision loss.
Activity Therapy; Cognitive Stimulation; Communication
Enhancement: Visual Deficit; Emotional Support; Environmental
Management; Exercise Therapy: Balance; Fall Prevention; Medication
Administration; Self-Esteem Enhancement; Surveillance: Safety
Reference
Whiteside, M. M., et al. (2006, November). Sensory impairment in older
adults: Part 2: Vision loss. American Journal of Nursing, 106(11), 5261.
SEXUAL DYSFUNCTION
DEFINITION
The state in which an individual experiences a change in sexual func-
tion during the sexual response phases of desire, excitation, and/or
orgasm, which is viewed as unsatisfying, unrewarding or inadequate
Alterations in achieving sexual dissatisfaction
Alterations in achieving perceived sex role
Actual limitations caused by disease
Actual limitations imposed by therapy
Change of interest in others
Change of interest in self
Inability to achieve desired satisfaction
Perceived alteration in sexual excitation
Perceived deficiency of sexual desire
Seeking confirmation of desirability
RELATED FACTORS
Absent role models Ineffectual role models
Altered body function Lack of privacy
Altered body structure Lack of significant other
Biopsychosocial alteration of Physical abuse
sexuality
Coping Pharmacological function
Knowledge
EXPECTED OUTCOMES
The patient will
Acknowledge problems or potential problems in sexual function.
Voice feelings about changes in sexual identity.
Express understanding of reason for sexual dysfunction.
Express willingness to obtain counseling.
Reestablish sexual activity at preillness level.
Adaptation to Physical Disability; Body Image; Fear Level; Physical
Aging; Role Performance; Sexual Functioning; Sexual Identity; Stress
Level
Determine: Access marital status, sexual patterns, living
arrangements, usual sexual patterns, attitudes toward modifying sex-
ual patterns, and knowledge about appropriate options available,
anxiety, loss. In combination with a general assessment, these factors
will help establish realistic outcomes for a plan.
337
Perform: Arrange for patient and partner to have periods of privacy
for sexual expression by closing the door, using a privacy sign, and
arranging with the staff to refrain from entering the room for a pre-
determined period of time. Hospital routines allow too few opportu-
nities for a patient to have private time. Sexual expression will not
occur where privacy does not exist.
Inform: Teach patient and partner about alternative methods of inti-
macy and expression of affection. This can raise patients self-esteem
until impotence is evaluated.
Teach coping strategies, including stress management and
relaxation techniques. Relaxation and decreased stress can increase
function, thereby improving strength and resistance.
Attend: Encourage patient to ask questions about personal sexuality.
A nonthreatening atmosphere encourages patients to ask questions
specifically related to the particular situation.
Provide support for the partner. Supportive interventions (such as
active listening) communicate concern, interest, and acceptance.
Suggest patient discuss concerns with partner. Open discussion
fosters sharing of concerns and strengthens relationship.
Manage: Suggest referral to a sex counselor or other appropriate
professional for future guidance to provide patient with a resource
for postdischarge support.
Anxiety Reduction; Emotional Support; Role Enhancement; Sex and
Counseling; Coping Enhancement: Environmental Management
Reference
Bakewell, R. T., & Volker, D. L. (2005, December). Sexual dysfunction related
to the treatment of young women with breast cancer. Clinical Journal of
Oncology Nursing, 9(6), 697702.
INEFFECTIVE SEXUALITY PATTERN

DEFINITION
Expressions of concern regarding own sexuality
Alterations in achieving perceived sex role
Alteration in relationship with significant other
Conflicts involving values
Reported changes in sexual behaviors
Reported changes in sexual activities
Reported difficulties in sexual behaviors
Reported difficulties in sexual activities
Reported limitations in sexual behaviors
Reported limitations in sexual activities
RELATED FACTORS
Absent role model Ineffective role model
Conflicts with sexual orienta- Knowledge/skill deficit about
tion or variant preferences alternative
Fear of acquiring a sexually Lack of privacy
transmitted disease Lack of significant other
Fear of pregnancy
Impaired relationship with a
significant other
Coping Knowledge
EXPECTED OUTCOMES
The patient will
Voice feelings about reported changes in sexual activity.
Express concern about self-concept, self-esteem, and body image.
State at least one effect of illness or treatment on sexual behavior.
The patient and partner will
Resume effective communication patterns.
Use available counseling referrals or support.
Anxiety Level; Body Image; Role Performance; Sexual Identity;
Stress Level
Determine: Assess for current treatment/medication regimen, marital
status and family members, perception of sexual identity and role, and
perception of changes in sexual activities resulting from illness or treat-
ment. Assessment information may help discover reasons for the prob-
lem and will assist to identify desirable outcomes and interventions.
339
Perform: Arrange to spend time each shift with the patient to
develop a trusting relationship. The patient may need to discuss his
or her difficulty but is more inclined to do that with a person he or
she trusts.
relaxation efforts usually help reduce anxiety.
Educate patient and partner about the illness and treatment.
Answer questions that might clarify any misconceptions they may
have. This may help them focus on specific concerns, encourage
questions, and avoid misunderstandings.
Attend: Provide time for privacy to allow the patient and his or her
partner to discuss feelings about sexuality and to engage in alterna-
tives for intimacy while the patient is in the hospital.
Be available to listen; accept patients feelings to let him or her
know that the feelings are valid and acceptable. A nonjudgmental
approach demonstrates unconditional positive regard for the patient
and his or her feelings.
Manage: Offer referral to counselors or support persons such as
mental health professional, sex counselor, and illness-related support
group to provide postdischarge support.
Anticipatory Guidance; Body Image Enhancement; Coping Enhance-
ment; Counseling; Emotional Support; Self-Awareness Enhancement;
Support Group
Reference
Christopherson, J. M., et al. (2006, June). A comparison of written materials
vs. materials and counseling for women with sexual dysfunction and multi-
ple sclerosis. Journal of Clinical Nursing, 15(6), 742750.
RISK FOR SHOCK

DEFINITION
At risk for an inadequate blood flow to the bodys tissues which
may lead to life-threatening cellular dysfunction
RISK FACTORS
Systemic inflammatory Sepsis
response syndrome Hypovolemia
Hypoxia Infection
Hypoxemia Hypotension
Cardiac function
Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain adequate blood pressure to provide tissue perfusion.
Not experience hemodynamic complications from underlying med-
ical condition.
Understand the need for aggressive management of underlying
medical condition in an effort to prevent shock.
Verbalize reportable signs and symptoms of possible hypotension
and hypoperfusion.
Tissue Perfusion: Cerebral; Hydration; Fluid Balance; Vital Signs
Determine: Monitor hemodynamic status frequently, including blood
pressure, heart rate, and oxygen saturation. Trending of vital signs
will provide database for early intervention and treatment.
Assess LOC with each vital sign check. Change in LOC is an
early indicator of cerebral hypoperfusion.
Perform: Administer intravenous fluids, oxygen, and medications as
prescribed to maintain fluid volume and organ perfusion.
Collect and evaluate serum laboratory specimens to provide data
to effectively treat underlying medical condition and avoid complica-
tion of shock.
Inform: Educate patient and family of reportable signs and
symptoms of inadequate perfusion, for example, dizziness,
confusion, restlessness, and dyspnea. Early intervention and
treatment is essential in preventing permanent organ damage.
Attend: Encourage patient and family to express concerns and fears
to reduce anxiety.
Manage: Collaborate with other members of the healthcare team to
effectively manage underlying medical condition and prevent compli-
cations.
341
AcidBase Monitoring; Fluid/Electrolyte Management; Hypovolemia
Management; Shock Management
References
Josephson, L. (2006). Cardiogenic shock. Dimensions of Critical Care Nursing,
27, 160170.
Krau, S. D. (2007). Making sense of multiple organ dysfunction syndrome.
Critical Care Nursing Clinics of North America, 19, 8797.
IMPAIRED SKIN INTEGRITY

DEFINITION
Altered epidermis and/or dermis
Destruction of skin layers
Disruption of skin surface
Invasion of body structures
RELATED FACTORS
External: chemical substances, Internal: changes in fluid sta-
extremes in age, humidity, tus, pigmentation, or turgor;
hyper- or hypothermia, developmental factors; imbal-
mechanical factorsshearing anced nutritional state
forces, pressure, restraint, obesity, emaciation; immuno-
medications, moisture, physi- logical deficit; impaired circu-
cal immobilization, and lation, metabolic state, or sen-
radiation sation; skeletal prominence
Knowledge Tissue integrity
EXPECTED OUTCOMES
The patient will
Show no evidence of skin breakdown.
Show normal skin turgor.
Regain skin integrity (specify); for example, pressure ulcer will
decrease in size.
Have a healed surgical wound.
Communicate understanding of skin protection measures.
Demonstrate skill in care of wound, burn, or incision.
Demonstrate skin inspection technique.
Perform skin care routine.
Communicate feelings about change in body image.
Immobility Consequences: Physiological; Tissue Integrity: Skin &
Mucous Membranes; Tissue Perfusion: Peripheral; Wound Healing:
Primary Intention; Wound Healing: Secondary Intention
Determine: Inspect skin every shift. Describe and document skin con-
dition, and report changes. These measures provide evidence of the
effectiveness of the skin care regimen.
Monitor frequency of turning and skin condition to reduce pres-
sure, promote circulation, and minimize skin breakdown.
343
Perform: Perform prescribed treatment regimen for the skin
condition involved and monitor progress. Report responses to the
treatment regimen to maintain or modify current therapy.
Provide supportive measures, as indicated:
Assist with general hygiene and comfort measures to promote
comfort and sense of well-being.
Administer pain medication and monitor its effectiveness.
Patient needs pain relief to maintain health.
Maintain proper environmental conditions to promote patients
sense of well-being.
Use a foam mattress, bed cradle, or other devices to minimize
skin breakdown.
Warn against tampering with the wound or dressings to reduce
potential for infection.
Maintain infection control standards to reduce the risk of
spreading disease.
Position patient for comfort and minimal pressure on bony promi-
nences. Change his or her position at least every 2 hr. These measures
reduce pressure, promote circulation, and minimize skin breakdown.
Inform: Explain the therapy to patient and family members to
encourage compliance.
Instruct patient and family members in a skin care regimen to
encourage compliance. Supervise patient and family members in skin
care management. Provide feedback to improve skill in managing
skin care.
Attend: Allow patient to express his or her feelings about skin prob-
lem. Verbalization of feelings helps allay anxiety and develops coping
skills.
Manage: Provide a referral to a psychiatric liaison nurse, social serv-
ice, or support group, as appropriate to provide additional support
for patient and his or her family.
Fluid Management; Infection Protection; Positioning; Pressure Man-
agement; Pressure Ulcer Care; Pressure Ulcer Prevention; Skin
Surveillance; Wound Care
Reference
Mackey, D. (2005, June). Support surfaces: Beds, mattresses, overlaysOh
My! The Nursing Clinics of North America, 40(2), 251265.
RISK FOR IMPAIRED SKIN INTEGRITY

DEFINITION
At risk for skin being adversely altered
RISK FACTORS
External: chemical substances, Internal: changes in fluid sta-
extremes in age, humidity, tus, pigmentation, or turgor;
hyper- or hypothermia, developmental factors; imbal-
mechanical factorsshearing anced nutritional stateobesity,
forces, pressure, restraint, emaciation; immunological
medications, moisture, deficit; impaired circulation,
physical immobilization, metabolic state, or sensation;
radiation skeletal prominence
Knowledge Tissue integrity
EXPECTED OUTCOMES
The patient will
Experience no skin breakdown.
Sustain adequate food and fluid intake.
Have intact mucous membranes.
Maintain adequate skin circulation.
Communicate understanding of preventive skin care measures.
Demonstrate preventive skin care measures.
Correlate risk factors and preventive measures.
Immobility Consequences: Physiological; Nutritional Status; Physical
Aging; Risk Control; Risk Detection; Tissue Integrity: Skin &
Mucous Membranes
Determine: Inspect skin every shift. Describe and document skin con-
dition and report changes. These measures provide evidence of the
effectiveness of the skin care regimen.
Monitor nutritional intake and maintain adequate hydration. Ane-
mia (less than 10 mg hemoglobin) and low serum albumin concen-
trations (less than 2 mg) are associated with the development of
pressure ulcers. Hydration helps maintain skin integrity.
Perform: Change patients position at least every 2 hr following turn-
ing schedule posted at bedside. Monitor frequency of turning. These
measures reduce pressure on tissues, promote circulation, and help
prevent skin breakdown.
345
Use preventive skin care devices, as needed, such as a foam mat-
tress, alternating pressure mattress, sheepskin, pillows, and padding,
to avoid discomfort and skin breakdown.
Keep patients skin clean and dry and lubricate as needed. Avoid
the use of irritating soap, and rinse skin well. These measures allevi-
ate skin dryness, promote comfort, and reduce the risk of irritation
and skin breakdown.
Protect bony prominences with foam padding. Prominences have
little subcutaneous fat and are prone to breakdown; using foam
padding may help promote skin integrity.
Lift patients body when moving him or her, using a lifting sheet,
if needed. Avoid shearing force. Shearing force results when tissues
slide against each other; a lifting sheet reduces sliding.
Keep linen dry, clean, and free from wrinkles or crumbs. Change
wet bed linens and incontinence pads immediately. Dry, smooth
linens help prevent excoriation and skin breakdown.
Inform: Educate patient and family in preventive skin care ways to
maintain good personal hygiene including use of nonirritating (non-
alkaline) soap; patting rather than rubbing skin dry; inspecting skin
regularly; avoiding prolonged exposure to water, sun, cold, and
wind; avoiding rubber rings; recognizing the beginning of skin
breakdown (redness, blisters, and discoloration); and reporting signs
and symptoms. These measures explain the importance of practicing
preventive skin care measures to encourage compliance with skin
care regimen.
Supervise patient and family in preventive skin care measures and
provide constructive feedback. Practice helps improve skill in manag-
ing the skin care regimen and encourages compliance.
Attend: Encourage ambulation or perform or assist with active
ROM exercises at least every 4 hr while patient is awake. Exercises
prevent muscle atrophy and contracture. Ambulation promotes cir-
culation and relieves pressure.
Manage: Indicate the risk factor potential on patients chart and care
plan and reevaluate weekly, using an accepted form such as the
Braden Scale. The risk factor score helps evaluate treatment
progress.
Circulatory Precautions; Infection Prevention; Positioning; Pressure
Management; Pressure Ulcer Prevention; Skin Surveillance; Splinting
Reference
Lyder, C. H. (2006, August). Assessing risk and preventing pressure ulcers in
patients with cancer. Seminars in Oncology Nursing, 22(3), 178184.
SLEEP DEPRIVATION
DEFINITION
Prolonged periods of time without sleep (sustained natural, periodic
suspension of relative consciousness)
Acute confusion Hallucinations
Agitation Hand tremors
Anxiety Heightened sensitivity to pain
Apathy Irritability
Combativeness Malaise
Daytime drowsiness Restlessness
Decreased ability to function Slowed reaction
Fatigue Transient paranoia
Fleeting nystagmus
RELATED FACTORS
Aging-related sleep stage shifts Narcolepsy
Dementia Nightmares
Familial sleep paralysis Periodic limb movement
Inadequate central nervous Sleep apnea
system hypersomnolence
Comfort Knowledge
Coping Pharmacologic function
Emotional Sleep/rest
EXPECTED OUTCOMES
The patient will
Identify factors that prevent or disrupt sleep.
Achieve uninterrupted sleep for ____ hr.
Express feelings of being well rested.
Show no signs of physical sleep deprivation.
Alter diet and habits to promote sleep.
Not exhibit sleep-related behavioral symptoms, such as irritability,
lethargy, listlessness, restlessness, anxiety, worry, or depression.
Perform relaxation exercise.
Concentration; Endurance; Energy Conservation; Mood Equilibrium;
Rest; Sleep; Stress Level; Symptom Severity
Determine: Assess usual sleep patterns, daytime activity and work
patterns, recent life changes, sleep environment, activities that pro-
mote sleep, and dietary and drug history. Information gained during
the assessment will assist in identifying outcomes and interventions.
347
Perform: Offer interventions to promote sleep, such as a warm bath,
back rub, comfortable positioning, additional pillows, and food or
drink. Personal hygiene routine precedes sleep for many individuals.
Milk and some high-protein snacks like cheese or nuts contain L-
tryptophan and are sleep promoters.
meditation, and progressive muscle relaxation. Practice them with
patient at bedtime. Purposeful relaxation efforts commonly promote
sleep.
Instruct patient to limit alcohol and caffeine intake. Avoid foods
and beverages with caffeine 45 hr before bedtime. Dietary changes
may help promote restful sleep.
Advise patient to avoid daytime naps to promote restful nocturnal
sleep.
Attend: Encourage patient to discuss factors in the environment that
make sleeping difficult. A strange or new environment may affect
REM and non-REM sleep.
Ask patient what changes would help promote sleep (such as
reducing noise, changing medication or treatment schedule, or
changing lighting) to encourage patient to play an active role in
care. Make immediate changes to accommodate patient.
Avoid quick, unanticipated movements when turning and position-
ing patients with neuromuscular dysfunction to prevent spasticity,
which may interrupt sleep.
Manage: Suggest a referral to sleep disorder center especially if daily
activities are affected or sleep apnea occurs. A specialist may be
required to assist in treatment.
Help patients with chronic illnesses or disabilities find resources
for addressing psychosocial issues. Fears and concerns about future
prevent restful sleep.
Anxiety Reduction; Energy Management; Comfort; Progressive
Muscle Relaxation; Sleep Enhancement
Reference
Frank, M. G. (2006). The mystery of sleep function: Current perspectives and
future directions. Review in Neuroscience, 17, 375392.
READINESS FOR ENHANCED SLEEP

DEFINITION
A pattern of natural, periodic suspension of consciousness that
provides adequate rest, sustains a desired lifestyle, and can be
strengthened
Amount of sleep is congruent with developmental needs
Expresses a feeling of rest after sleep
Expresses willingness to enhance sleep
Follows sleep routines that promote sleep habits
Occasional use of medications to induce sleep
Activities Pharmacologic function
Knowledge Sleep/rest
EXPECTED OUTCOMES
The patient will
Identify factors that enhance readiness for sleep.
Demonstrate readiness for enhanced sleep through the use of
appropriate sleep hygiene measures.
Express feeling rested after sleep.
Have an appropriate amount of sleep and REM sleep that is con-
gruent with developmental needs.
Anxiety Level; Rest; Sleep
Determine: Assess daytime activity and work patterns; cognitive sta-
tus; daytime consequences of sleeplessness; sleep environment; qual-
ity and duration of sleep; recent changes in health status or lifestyle;
and dietary and drug history, including ingestion of caffeine or other
stimulants.
Assessment information will help identify appropriate outcomes
and interventions.
Perform: Give warm, light snacks containing protein at bedtime and
small amounts of liquid to promote a sense of comfort.
Provide a cup of water close to bedtime to avoid dry mouth and
help return to sleep after awakening.
Inform: Educate patient about normal age-related changes to sleep
and strategies that are specific to the patients health status, lifestyle,
and environment to decrease anxiety about sleeplessness.
Teach patient to relax before going to bed, using music, reading,
meditation, or other soothing or comforting activities to enhance
ability to sleep.
349
Instruct patient to avoid dietary substances and drugs that may
influence sleep, including ingestion of caffeine or other stimulants,
nicotine, alcohol, sedatives, hypnotics, and fluid intake, to enhance
the ability to sleep.
Attend: Encourage patient to make a log of sleep and wake times,
number of awakenings, total time asleep, quality of sleep, and any
precipitating factors that may influence sleep to determine sleep
efficiency.
Manage: If patient begins having difficulties sleeping, recommend a
behavior modification plan based on assessment of condition,
patients history, and precipitating factors to enhance compliance.
Comfort; Sleep Enhancement
Reference
Page, M. S., et al. (2006, December). Putting evidence into practice: Evidence-
based interventions for sleepwake disturbances. Clinical Journal of Oncology
Nursing, 10(6), 753767.
IMPAIRED SOCIAL INTERACTION

DEFINITION
Insufficient or excessive quantity or ineffective quality of social
exchange
Discomfort in social situations
Dysfunctional interaction with others
Family report of interaction with others
Inability to communicate a satisfying sense of social engagement
Inability to receive a satisfying sense of social engagement
Use of unsuccessful social interaction
RELATED FACTORS
Absence of significant others Environmental barriers
Communication barriers Self-concept disturbance
Deficit about ways to enhance Sociocultural dissonance
mutuality Therapeutic isolation
Behavior Knowledge
Coping
EXPECTED OUTCOMES
The patient will
Provide information concerning cultural background.
Identify needs and communicate (verbally or through behavior)
whether needs are met.
Express understanding of care-related instructions.
Participate in planning care.
Identify effective coping techniques to deal with sociocultural
differences.
Express feelings of comfort and trust in interacting with
caregivers.
Use resources outside normal sociocultural group, as necessary.
Communication; Social Interaction Skills; Social Involvement; Stress
Levels
Determine: Assess sociocultural background; usual pattern of social
interaction; dominant language; position in family; support systems,
including clergy, family members, and friends; and education and
level of intelligence. Assessment information will help identify appro-
priate outcomes and interventions.
Perform: Assist patient with self-care activities of bathing, grooming,
eating, and toileting. Encourage patient to do as much as possible in
351
order to reduce feelings of helplessness and to build a sense of con-
trol over current situation.
Explain care-related activities clearly and answer questions as
accurately as possible to enhance the patients understanding of pro-
cedures and facility routines.
Inform: Teach patient to use effective social interaction behaviors,
such as increased eye contact, calling people by name, and asking
questions. Teaching patient effective communication skills helps him
or her function more effectively in a social environment.
Attend: Provide a specific time to talk to the patient and family
about their sociocultural background. In many cultural groups, trust
develops slowly and may be hampered by lengthy interviews.
Involve patient and family members in planning care and in
encouraging patients participation in self-care to increase their sense
of control over the present situation.
Demonstrate respect for the patients privacy, personal belongings,
cultural norms, and religious beliefs and practices to demonstrate
sensitivity to patients from varied cultural backgrounds.
Manage: Use an interpreter when necessary to ensure effective com-
munication with non-English-speaking patients. The primary reasons
to use an interpreter to communicate with a patient are legal and
financial and to provide quality care.
Involve family, friends, and clergy to provide appropriate spiritual
support.
Active Listening; Anxiety Reduction; Coping Enhancement; Family
Support; Normalization Promotion Spiritual Support
Reference
Van Servellen, G., et al. (2006, September). Continuity of care and quality
outcomes for people experiencing chronic conditions: A literature review.
Nursing & Health Sciences, 8(3), 185195.
SOCIAL ISOLATION
DEFINITION
Aloneness experienced by the individual and perceived as imposed
by others and as a negative or threatening state
Absence of supportive significant others
Dull affect
Evaluation of self as being unable to deal with situations or events
Expressions of helplessness
Experiences feelings of differences from others
Expressions of uselessness
Failure to make eye contact
Illness
Indecisive behavior
Insecurity in public
Meaningless eye contact
Preoccupation with own thoughts
Uncommunicative
Sad affect
RELATED FACTORS
Alterations in mental status Inability to engage in satisfy-
Alterations in physical ing personal relationships
appearance Inadequate personal resources
Altered state of wellness Unaccepted social values
Immature interests Unaccepted social behavior
Behavior Emotional
EXPECTED OUTCOMES
The patient will
Express feelings associated with social isolation.
Identify possible causes of social isolation and participate in devel-
oping plan for increasing social activity.
Interact with family members, friends, and caregivers.
Perform self-care activities independently.
Participate daily in meaningful diversional activity.
Indicate that social relationships have improved and negative feel-
ings have diminished.
Achieve expected state of wellness.
Leisure Participation; Loneliness Severity; Personal Well-Being; Social
Interaction Skills; Social Involvement; Social Support
353
Determine: Assess reason for hospitalization, family support systems
available, functional ability, financial resources, occupation, educational
level, and coping and problem-solving ability. Assessment information
will assist in identifying appropriate outcomes and interventions.
Perform: Assist patient with daily self-care activities, such as bathing,
grooming, dressing, eating, and ambulating. Encourage patient to
take on more of this responsibility for self, as he or she is able. This
will reduce feelings of helplessness.
family such as meditation, guided imagery, yoga, and prayer to pre-
positive decisions.
Teach patient coping techniques to help increase ability to deal
with especially challenging situations.
Attend: Encourage patient to express feelings about herself (past and
present). Self-exploration encourages patient to consider future change.
Encourage patient to identify the causes of social isolation to help
her to develop a plan to reduce the isolation she is experiencing.
Provide private time for patient to spend with family, including spe-
cific amount of noncore time to engage patient in conversation. Such
discussions help patient assume responsibility for coping responses.
Provide patient with positive feedback for verbal reports or behav-
iors that indicate a return to positive self-appraisal. This gives
help her cope effectively with stressful situations.
Provide emotional support to family by being available to answer
questions. Accurate information will help family cope with current
situation.
Manage: Arrange with patient specific periods for appropriate diver-
sional activity to provide pleasure, increase feelings of self-worth,
and decrease negative self-absorption.
which they plan to enhance their coping skills in the present situation.
Refer family to community resources and support groups available
to assist in managing patients illness and providing emotional and
Activity Therapy; Family Integrity Promotion; Mood Management;
Socialization Enhancement; Support System Enhancement
Reference
McClung, E. (2006, June). Collaborating with chaplains to meet spiritual
needs. Medsurg Nursing, 15(3), 147156.
CHRONIC SORROW
DEFINITION
Cyclical, recurring, and potentially progressive pattern of pervasive
sadness experienced (by a parent, a caregiver, and an individual with
chronic illness or disability) in response to continual loss, through-
out the trajectory of an illness or disability
Expresses negative feelings (e.g., anger, being misunderstood, con-
fusion, depression, disappointment, emptiness, fear, frustration,
guilt, self-blame, helplessness, hopelessness, loneliness, low self-
esteem, recurring loss, overwhelmed)
Expresses feelings of sadness (e.g., periodic recurrent)
Expresses feelings that interfere with ability to reach the highest
level of social well-being
RELATED FACTORS
Crisis in management of the Experiences chronic disability or
illness illness (e.g., physical or mental)
Crisis related to developmental Missed opportunities
stages Missed milestones
Death of a loved one Unending caregiving
Behavior Nutrition
Communication Sleep patterns
Emotional
EXPECTED OUTCOMES
The patient will
Identify losses associated with changes in health status.
Express feelings about changes in health status.
Seek assistance in dealing with emotions related to loss.
Develop healthy coping mechanisms such as open expression of grief.
Seek out support from family, friends, clergy, or others when
necessary.
Begin to plan for discharge and the future.
Express realistic expectations with regard to health.
Acceptance: Health Status; Depression; Self-Control; Hope;
Mood Equilibrium
Determine: Assess history of recent loss; usual pattern of coping;
behavioral manifestation of grief and loss; sleep problems; lifestyle
changes related to the situation; appetite; change in weight;
religious beliefs and practices; and sources of support. Assessment
355
information will help identify appropriate outcomes and
interventions.
Perform: For patient who has lost weight, weigh daily at the same
time to evaluate improvements in nutrition.
Provide bathing, grooming, and other hygiene functions for
possible for himself or herself. Greater independence will help build
self-esteem.
Inform: Teach skills that enhance coping strategies and relaxation
strategies such as meditation, guided imagery, yoga, exercise. These
mechanisms help reduce the level of anxiety that prevents the
patient from coping with grief and loss.
Attend: Let patient know that expressions of anger are acceptable,
but place limits on destructive behavior. Inability to identify anger
as a normal response to loss may cause patient to express aggression
inappropriately.
Encourage patient to reach out to people who can offer emotional
support in order to increase emotional support. Sensitive listening
provides emotional support that can allow the patient to broaden
his or her focus beyond the cause of the sorrow.
Encourage patient and family to reminisce. Engaging in life review
promotes a peaceful atmosphere and helps understanding the mean-
ing of loss in relation to health and life.
Encourage patient to take an active part in setting goals for
healthcare to facilitate independence and enhance self-esteem.
Refer patient and family to other professional caregivers (e.g.,
dietitian, social worker, clergy, mental health professional). Support
groups can be helpful to the patient and the family.
Coping Enhancement; Decision-Making Support; Emotional Support;
Hope Installation; Mood Management; Spiritual Support
Reference
Chao, S. Y., et al. (2006, March). The effects of group reminiscence therapy
on depression, self-esteem, and life satisfaction of elderly nursing home resi-
dents. The Journal of Nursing Research 14(1), 3645.
SPIRITUAL DISTRESS
DEFINITION
Impaired ability to experience and integrate meaning and purpose in
life through connectedness with self, others, art, music, literature,
nature, and/or a power greater than oneself
Anger
Expresses lack of acceptance
Expresses lack of courage
Expresses lack of forgiveness of self
Expresses lack of meaning in life
Expresses lack of purpose in life
Expresses lack of serenity
Inability to express previous state of creativity
Inability to experience the transcendent
Inability to participate in religious activities
Refuses interaction with spiritual leaders
Verbalizes being separated from support system
RELATED FACTORS
Active dying Loneliness
Anxiety Pain
Chronic illness Self-alienation
Death Social alienation
Life change Sociocultural deprivation
EXPECTED OUTCOMES
The patient will
Communicate conflicts about beliefs.
Identify understanding of source of spiritual conflict.
Specify whatever spiritual assistance is perceived as needed.
Discuss beliefs about religious practices.
Identify coping techniques to deal with spiritual discomfort and
not harm self while in the hospital.
Impulse Self-Control; Risk Control; Self-Mutilation Restraint
Determine: Assess behavioral responses; coping strategies; experiences
with illness; knowledge; environment, social factors; spiritual beliefs
and practices; and spiritual support system. Assessment information
will help the nurse identify appropriate interventions.
357
Perform: Assist the patient to list those aspects of spiritual care he
or she would like the hospital to provide. Having documentation
from the patient is useful to communicate the patients spiritual
needs with the staff.
Spend time with the patient developing goals for skill development
that will help the patient deal with his or her current diagnosis.
Without the necessary skills, the patient will continue to feel
distressed and anxious.
Inform: Teach patients coping strategies to family members and
friends so they can help patient practice adaptive methods of coping
with self-destructive feelings.
Teach self-healing techniques and relaxation strategies to both the
patient and family such as meditation, guided imagery, yoga, and
prayer. These techniques can reduce the anxiety that comes from
attempting to cope with his or her disease. Teach patient how to
daily activities.
Self-healing gives the patient a better sense of control over regain-
ing independence.
Attend: Acknowledge patients spiritual concerns and encourage
expression of thoughts and feelings to help build a therapeutic rela-
tionship.
For the patient whose spiritual comfort is derived from music, art,
or nature, attempt to find such items (e.g., CDs, posters, or picture
books) that will provide spiritual nourishment. Not everyone finds
spiritual comfort in organized religion. Each person is entitled to
find spiritual hope and consolation in whatever way his or her needs
are met.
Encourage patient to continue religious practices while in the hos-
pital; do whatever you must to facilitate this. These measures
demonstrate support and convey caring and acceptance.
Manage: Communicate and collaborate with patients clergy person
or with the hospital chaplain, as appropriate. This ensures consistent
care and provides a more complete database.
Active Listening; Hope Instillation; Referral; Spiritual Growth Facili-
tation; Spiritual Support
Reference
Mohr, W. K. (2006, August). Spiritual issues in psychiatric care. Perspectives
in Psychiatric Care, 4(3), 174183.
RISK FOR SPIRITUAL DISTRESS

DEFINITION
At risk for an impaired ability to experience and integrate meaning
and purpose in life through connectedness with self, others, art,
music, literature, nature, and/or a power greater than oneself that
can be strengthened
RISK FACTORS
Anxiety Inability to forgive
Blocks to experiencing love Life changes
Change in spiritual practices Low self-esteem
Chronic illness Natural disasters
Cultural conflict Racial conflict
Environmental changes Substance abuse
Behavior Self-perception
Emotional
EXPECTED OUTCOMES
The patient will
Discuss current beliefs and concerns.
Discuss effects of illness, injury, or disability on beliefs and spiri-
tual practices.
Express feelings of spiritual well-being.
Use healthy coping techniques to maintain spiritual well-being.
Refrain from causing harm to self.
Be supported in efforts to pursue spirituality in coping with illness
or disability.
Reach out to family members, clergy, or friends for assistance.
Coping; Grief Resolution; Hope; Spiritual Health
Determine: Assess health history; impact of the current illness on
lifestyle; spiritual status; religious affiliation; relationship with spiritual
leaders; importance of spirituality in the patients life; desire for help in
coping with spiritual concerns; family status; and socioeconomic status.
Assessment information will assist in identifying appropriate inter-
ventions.
Inform: Teach coping strategies that appeal to the patient such as medi-
tation, relaxation, guided imagery. This will help the patient focus on
what he or she would like to achieve in his or her spiritual life.
Attend: Express your willingness to discuss spirituality if the patient
desires. This helps reduce isolation and bring spiritual realities into
the open.
359
Be certain about understanding your own beliefs and accept the
patients beliefs even if they are different from your own. It is essen-
tial to understand what you believe in order to listen and be
nonjudgmental when listening to the patient. It is unacceptable for
the nurse to argue with the patient about spiritual beliefs.
Communicate to the patient that you accept his or her expression
of spiritual concerns, even if his or her feelings are angry and nega-
tive to reassure him or her that his feelings are valid. The feeling of
acceptance will facilitate the patients ability to express his or her
spiritual issues more freely.
Listen attentively to patients discussion of spiritual concerns.
Thoughtful listening fosters open discussion.
Encourage patient to discuss recent life-threatening experience to
help him or her clarify and cope with his or her feelings.
Provide for continuation of the patients religious practices. For
example, help patient obtain ritual items and respect dietary restric-
tions, if possible, to demonstrate support and convey caring and
acceptance to patient.
Manage: Collaborate with patients clergy person or hospital chap-
lain to develop a plan to integrate spiritual interventions into
patients care to ensure continuity of care.
Active Listening; Anticipatory Guidance; Anxiety Reduction; Care-
giver Support; Hope Instillation; Spiritual Growth Facilitation; Spiri-
tual Support
Reference
Bauer-Wu, S., & Farran, C. J. (2005, June). Meaning in life and psycho-
spiritual functioning: A comparison of breast cancer survivors and healthy
women. Journal of Holistic Nursing, 23(2), 172190.
READINESS FOR ENHANCED SPIRITUAL

WELL-BEING
DEFINITION
Ability to experience and integrate meaning and purpose in life
through connectedness with self, others, art, music, literature, nature,
and/or a power greater than oneself that can be strengthened
Expresses desire for enhanced acceptance
Expresses desire for enhanced coping
Expresses desire for enhanced courage, hope, and surrender
Expresses desire for enhanced joy, love, and meaning in life
Expresses lack of serenity
Meditation
Provides service to others
Requests interactions with significant others
Requests interactions with spiritual leaders
Listens to music
Reads spiritual literature
Expresses awe and reverence
Prays
Reports mystical
Knowledge
EXPECTED OUTCOMES
The patient will
Be able to articulate strengths and competencies in managing ther-
apeutic regimen.
Set goals that enhance therapeutic regimen.
Develop plans to maximize behaviors directed at enhancing thera-
peutic regimen.
Identify types of support needed to enhance health behaviors.
Knowledge; Treatment Regimen; Symptom Control; Treatment
Behavior; Illness
Determine: Assess personal religion and church affiliation;
perceptions of faith, life, death, suffering; support networks; beliefs
opposed by family, friends, healthcare providers. Assessment of spiri-
tual status will provide information that will assist in identifying
expected outcomes and interventions for this diagnosis.
361
Perform: Monitor the patient for signs of spiritual distress that
might harm the patients well-being (altered self-care, sleep pattern
disturbance, and change in eating and exercise habits). This informa-
tion will provide insight into changes in goals and interventions.
Assess the significance of spirituality in the patients life and in
coping with illness. Before the nurse can intervene in spiritual mat-
ters, she must determine whether spirituality is significant for the
patient.
Inform: Provide the patient with resources for coping with spiritual
distress (such as referrals to religious or spiritual organizations or
books on prayer or meditation) to enhance the opportunity to
attend to spiritual beliefs.
If the nurse lacks knowledge about the patients beliefs or
practices, consult an authority on the patients particular religion to
have accurate information when endeavoring to meet his or her
individual needs.
Discuss importance of maintaining a healthy diet, regular exercise,
adequate sleep, and healthy interaction with family members and
friends. A patient who is predisposed to spiritual distress may neg-
lect day-to-day well-being.
Attend: Demonstrate to the patient that you are willing to discuss
issues related to spirituality, such as the patients view of God, how
illness has affected his life, or how the hospital stay has affected his
or her spiritual practices to bring spiritual issues into the open.
Praise patients efforts to attend to his or her spiritual needs and
encourage him or her to continue to develop spirituality after he or
she leaves the healthcare setting to reinforce the progress the patient
has already made.
Manage: Provide patient with referrals to appropriate religious
groups, spiritually centered organizations, and social service organi-
zations to help provide additional support and to ensure continuity
of care.
Consider resources such as parish nurses, home visiting services,
and computer networks to help provide continued opportunity for
spiritual development and ensure continuity of care.
Active Listening; Emotional Support; Hope Instillation; Presence;
Spiritual Growth Facilitation; Spiritual Support
Reference
Gaskamp, C., et al. (2006, November). Evidence-based guideline: Promoting
spirituality in the older adult. Journal of Gerontological Nursing, 321(11),
813.
STRESS OVERLOAD
DEFINITION
Excessive amounts and types of demands that require action
Demonstrates increased feelings of anger or impatience
Expresses difficulty in functioning
Expresses a feeling of pressure or tension
Expresses problems with decision making
Reports negative impact from stress (physical or psychological
symptoms)
Reports situational stress as excessive
RELATED FACTORS
Inadequate resources Multiple coexisting stressors
(financial, social, educational) (environmental threats, physi-
Intense, repeated stressors cal threats)
(family violence, chronic or
terminal illness)
Behavior Pharmacological
Emotional Sleep/rest
EXPECTED OUTCOMES
The patient will
Experience reduced signs of stress overload as evidenced by subjec-
tive report and observations of reduced stress, such as less facial
tension and less restlessness.
Connect environmental stressors with manifestations of stress such
as insomnia, tearful outbursts, irritability, or headache.
Set limits on activities assumed by saying no without expressions of
guilt.
Develop more effective coping strategies to manage stress such as
guided imagery, exercise, healthy diet, and recreation and leisure
activities.
Develop strategies to reframe distorted thinking patterns relating
to internal and environmental demands, such as talking about
feelings and asking for help.
Abusive Behavior; Aggression Self-Control; Anxiety Self-Control;
Coping; Self-Restraint; Stress Level
363
Determine: Establish and promote a trusting relationship before ask-
ing patient to make any changes. A trusting relationship can facilitate
patients attempts to make changes, whereas too many demands
early in relationship can foster resistance.
Perform: Explore support systems with patient, such as appropriate
Internet chat rooms, support groups, or hobbies and outings with
partner or family and friends. Often patient is caretaker who
perceives there is little time for self and is at risk for caregiver bur-
den. Promoting verbalization of feelings with support persons can
reduce feeling of stress overload.
Explore the lack of exercise, and excessive intake of caffeine, alco-
hol, nicotine, and carbohydrates during periods of stress overload and
adoption of healthier alternatives. Inappropriate food choices, inactiv-
ity, and substance abuse can occur when patient feels stress overload.
Inform: Teach prioritization of responsibilities and deadlines to facili-
tate patients sense of control over stressors. Stressors may seem
overwhelming, and nurse can promote increased self-esteem when a
plan is made cooperatively with nurse and patient as partners.
Teach patient about positive self-talk. Positive self-talk helps change
and, ultimately, reverse negative emotions of guilt, fear, and worry.
Teach coping strategies such as reframing thoughts or using music,
guided imagery, yoga, deep-breathing exercises, progressive neuromuscu-
lar relaxation, or pet therapy. Strategies that reduce tense muscles and
feelings can promote deeper relaxation and reduce heart rate, respira-
tions, and blood pressure by promoting the parasympathetic response.
Teach assertiveness training techniques with role-play exercises.
Assertiveness training can provide a concrete way to manage stres-
sors and enhance feeling of being empowered, such as in communi-
cating with demanding individuals.
Attend: Provide opportunities for patient to ventilate feelings about
stressors. Promoting a time to talk can help the patient share his or
her feelings of mounting stress before irritability and tension worsen.
port group, or other mental health provider. Stress may be an indi-
cator of other more serious mental health problems.
Anger Control Assistance; Assertiveness Training; Behavior Manage-
ment; Behavior Modification; Calming Techniques; Cognitive
Restructuring; Coping Enhancement; Impulse Control Training;
Stress Management Assistance
Reference
Learn Well Resources. (2006, January). Managing stress: Living without stress
overload. Course Number LWH102.
RISK FOR SUFFOCATION

DEFINITION
Accentuated risk of accidental suffocation (inadequate air available
for inhalation)
RISK FACTORS
Access to unattended bathtub Household gas leaks
Consumption of large amounts Vehicle warming in a closed
of food garage
Discarded refrigerators or Cognitive difficulties
freezers with doors still in Disease process
place Emotional difficulties
Fuel burning heater used with- Lack of safety precautions
out ventilation Reduced motor abilities
Habit of smoking in bed Reduced olfactory sensation
Self-care
Knowledge
Values/beliefs
EXPECTED OUTCOMES
The patient will
Demonstrate a patent airway at all times.
Maintain vital signs within normal parameters.
Demonstrate along with family knowledge of safety measures to
prevent suffocation.
Aspiration Prevention; Personal Safety Behavior; Respiratory Status:
Ventilation; Risk Control; Risk Detection
Determine: Assess vital signs; history of current situation; neurologic
status; and hemoglobin, hematocrit, clotting factors, platelet count,
and WBC; mental illness; history of abuse. Assessment information
will assist in formulating goals and interventions.
Perform: Position patient on side or position head and neck to
prevent relaxed neck muscles from obstructing airway to allow
maximal chest expansion and prevent aspiration and airway
obstruction.
Check all ventilator connections and alarms every 30 min if
patient is on mechanical ventilation to ensure that patient receives
the proper amount of oxygen at appropriate volume and rate.
Suction airway, as needed, to prevent accumulation of secretions.
Suction only as needed to prevent tracheal irritation.
Position patient on his or her side or position his or her head and
neck to prevent relaxed neck muscles from obstructing the airway.
365
This allows maximal chest expansion and prevent aspiration and
airway obstruction.
Obtain suction equipment, assemble, and keep at bedside to
ensure equipment readiness in case it is needed.
Inform: Educate patients family about safety measures in the home,
for example, proper positioning, suction procedure, fall prevention
to enable them to take an active role in the patients care and
ensure performance of safety measures.
Attend: Be attentive to the fears of both patient and family. Listen
with sensitivity and reinforce safety measures to prevent injury. To
achieve a level of comfort, the family may need to ask the same
questions multiple times and have the information repeated
frequently.
Manage: Offer referral to counselors or support persons, as needed.
Many families will need additional support after hospitalization.
Airway Management; Aspiration Precautions; Energy Management;
Vital Signs Monitoring
Reference
Westergren, A. (2006, June). Detection of eating difficulties after stroke: A sys-
tematic review. International Nursing Review, 53(2), 143149.
RISK FOR SUICIDE

DEFINITION
At risk for self-inflicted, life-threatening injury
RISK FACTORS
Behavioral: Buying a gun, Situational: Adolescents living
changing a will or creating a in nontraditional settings (e.g.,
will, giving away possessions, juvenile detention center,
history of prior attempts, prison, half-way house, group
marked changes in attitude or home), economic instability,
behavior, stockpiling loss of autonomy or independ-
medicines, or sudden euphoric ence, relocation
recovery from depression Social: Cluster suicides,
Demographic: Age (e.g., elderly, disrupted family life, discipli-
young adult males, adolescents), nary problems, grief, helpless-
divorced or widowed, gender ness, hopelessness, legal
(male), and race (e.g., problems, loneliness, loss
Caucasian, Native American) of important relationship,
Physical: Chronic pain, physi- poor support systems, social
cal illness, or terminal illness isolation
Psychological: Childhood Verbal: states desire to die
abuse, family history of or makes threats of killing
suicide, gay or lesbian youth, oneself
guilt, psychiatric illness or
disorder (e.g., depression,
schizophrenia, bipolar
disorder), or substance abuse
Behavior Pharmacological function
Emotional
EXPECTED OUTCOMES
The patient will
Discuss feelings that precipitate suicide attempts.
Refrain from harming self.
Recover from suicidal episode.
Consult with mental health professional.
Voice improvement in feelings of self-worth.
Depression Level; Mood Equilibrium; Risk Control; Self-Esteem;
Social Support
Determine: Assess medical history, life situation, recent stressors,
coping skills, history of suicidal attempts, history of substance
367
abuse, safety hazards, and medications. Assessment results will pro-
vide information that will assist in identifying goals and selecting
Perform: Initiate suicidal precaution protocol, including checks every
15 min to ensure that the patient is protected and is in a safe envi-
ronment.
Remove anything from the patients environment that could be
used to inflict injury to self such as razor blades, belts, glass objects,
knives, pills, cans, and mirrors. This helps ensure the patients safety.
meditation, and progressive muscle relaxation. Practice them with
patient at bedtime. Purposeful relaxation efforts commonly promote
sleep.
Attend: Use nonjudgmental manner to show unconditional positive
regard.
Listen carefully to patient and avoid challenging him or her in
order to communicate caring and support.
Demonstrate caring but do not reinforce denial of current
situation because roots of suicidal feelings can be masked by denial.
Encourage patient to participate in group activities, especially
those he or she enjoys to help build self-esteem. Assist patient to
recognize inappropriate coping mechanisms and help identify those
that enhance personal well-being to use strengths and skills in pre-
venting self-destructive behavior.
Manage: Make a referral to mental health professional to help
patient through suicidal ideations and develop healthier alternatives.
Coping; Behavior Management; Environmental Management;
Suicide Prevention
Reference
Ortiz, M. (2006, December). Staying alive! A suicide prevention overview.
Journal of Psychosocial Nursing and Mental Health Services, 44(12), 4349.
DELAYED SURGICAL RECOVERY

DEFINITION
Extension of the number of postoperative days required to initiate
and perform activities that maintain life, health, and well-being
Evidence of interrupted healing of surgical area
Loss of appetite with or without nausea
Perception that more time is needed to recover
Postpones resumption of work or employment activities
Report of pain and/or fatigue.
Requires help to move about and/or complete self-care.
RELATED FACTORS
Extensive surgical procedure Pain
Infection of postoperative Preoperative expectations
surgical site Prolonged surgical procedure
Obesity
EXPECTED OUTCOMES
The patient will
Have vital signs and laboratory values within normal limits.
Have evidence of wound healing; incision site will appear free
from signs and symptoms of infection.
Have resolution of any postoperative complications.
Resume normal mobility status.
Seek and obtain emotional support from family and friends.
Resume normal eating, bowel, and bladder habits.
Use community resources that are available to assist after discharge.
Ambulation; Endurance; Health Beliefs; Immobility Consequences:
Physiological; Nutritional Status; Pain Level; Wound Healing:
Primary Intention
Determine: Assess all body systems to detect signs and symptoms of
postoperative complications that delay surgical recovery.
Assess surgical site for signs of infection, such as erythema,
edema, pain, drainage, odor, incision approximation, and intact
sutures. Monitor wound healing. Document and report assessment
findings to facilitate the development of an individualized care plan.
Monitor nutritional status optimal nutritional status promotes
wound healing and provides energy for recovery.
369
Monitor bowel and bladder activity. Report urine retention and
absent or decreased bowel sounds. Abnormal bowel and bladder
patterns slow surgical recovery.
Following postoperative bleeding, monitor hemoglobin level and
hematocrit. Bleeding can lead to a low hemoglobin level and hemat-
ocrit, reducing the ability of red blood cells to carry oxygen, which
can hinder wound healing and diminish patients energy level.
Perform: Follow proper pulmonary regimen to facilitate resolution of
respiratory complications, if present, which lead to decreased oxygen
levels, slow would healing and delayed mobility.
If patient suffers from psychosis, continue to reorient during post-
operative recovery period to prevent delay in recovery and report
psychological reaction (e.g., depression-like symptoms).
Administer pain medication, as prescribed. A patient in pain wont
move, cough, and deep-breathe as needed for timely recovery.
As appropriate, make sure that someone is available to walk with
patient or assistive devices (walkers or canes) are available. Dont
allow patient to ambulate alone until steady. Assistance enhances
safety and encourages patient to improve mobility without fear of
falling. Mobility facilitates improved strength, helps prevent such com-
plications as deep vein thrombosis, and, ultimately, enhances recovery.
Enforce use of support stockings or a sequential compression
device to facilitate venous return and prevent deep vein thrombosis.
Inform: Educate patient and family regarding appropriate care after dis-
charge to promote compliance with medication and treatment regimens.
Attend: Make sure patient and family members have access to com-
munity resources to assist with recovery when patient returns home
to ensure ongoing recovery.
Manage: Initiate an interdisciplinary care conference for patient to
help develop a plan that will put the patient on a faster track to
recovery.
Bed Rest Care; Case Management; Discharge Planning; Energy
Management; Exercise Therapy: Ambulation; Incision Site Care;
Multidisciplinary Care Conference; Nutrition Management; Pain
Management; Sleep Enhancement
Reference
Bedard, D., et al. (2006, September). The pain experience of post-surgical
patients following implementation of an evidence-based approach. Pain
Management Nursing, 7(3), 8092.
IMPAIRED SWALLOWING
DEFINITION
Abnormal functioning of the swallowing mechanism associated with
deficits in oral, pharyngeal, or esophageal structure or function
Esophageal phase impairment (observed evidence of difficulty in
swallowing, heartburn or epigastric pain, food refusal, complaints
of something stuck)
Oral phase impairment (choking or coughing before a swallow,
drooling, gagging, inability to clear oral cavity, food falls from
mouth)
Pharyngeal phase impairment (delayed swallow, choking or cough-
ing, multiple swallows, recurrent pulmonary infections, food
refusal)
RELATED FACTORS
Congenital defects (congenital heart disease, neuromuscular
impairment, protein energy malnutrition, hypotonia, upper airway
anomolies)
Neurological problems (achalasia, cerebral palsy, gastroesophageal
reflux, laryngeal or nasal defects, prematurity, trauma)
Neurocognition Respiratory function
EXPECTED OUTCOMES
The patient will
Show no evidence of aspiration pneumonia.
Achieve adequate nutritional intake.
Maintain weight.
Maintain oral hygiene.
Demonstrate correct feeding techniques to maximize swallowing.
List strategies to prevent aspiration.
Appetite; Aspiration Prevention; Cognition; Nutritional Status: Food
& Fluid Intake; Swallowing Status; Swallowing Status: Esophageal
Phase; Swallowing Status: Oral Phase; Swallowing Status: Pharyngeal
Phase
Determine: Monitor intake and output and weight daily until stabi-
lized. Establish an intake goal (specify), Patient consumes ____ ml
of fluid and ____ % of solid food. Record and report any
deviation from this. Evaluating calorie and protein intake daily
allows any necessary modifications to begin quickly.
371
Perform: Elevate head of the bed 90 during mealtimes and for 30 min
after the completion of a meal. Position patient on his or her side
when recumbent. These measures decrease the risk of aspiration.
Keep suction apparatus at the bedside to be prepared for episodes
of aspiration that require immediate suctioning. Observe and report
instances of cyanosis, dyspnea, or choking. Symptoms indicate the
presence of material in the lungs.
Provide mouth care three times daily. Keep oral mucous membrane
moist by frequent rinses; use a bulb syringe or suction if necessary.
These measures promote comfort and enhance appetite. Lubricate
patients lips to prevent cracking and blisters.
Inform: Teach patient and family about positioning, dietary require-
ments, and specific feeding techniques to allow patient to take an
active role in maintaining health. These include facial exercises (such
as whistling) to promote muscle activity, using a short straw to pro-
vide sensory stimulation to the lips, tipping the head forward to
decrease aspiration, applying pressure above the lip to stimulate
mouth closure and the swallowing reflex, and checking the oral cav-
ity frequently to determine presence of food particles (remove if
present).
Attend: Encourage patient to wear properly fitted dentures to
enhance chewing ability.
Serve food in attractive surroundings. Encourage patient to smell
and look at food. Remove soiled equipment, control smells, and
provide a quiet atmosphere for eating. A pleasant atmosphere stimu-
lates appetite. Food aroma stimulates salivation.
Manage: Consult with a dietitian to modify patients diet, and conduct
a calorie count, as needed, to establish nutritional requirements.
Consult with a dysphagia rehabilitation team, if available, to
obtain expert advice.
Airway Suctioning; Aspiration Precautions; Feeding; Positioning;
Referral; Risk Identification; Swallowing Therapy
Reference
Lorefalt, B., et al. (2006, November). Avoidance of solid food in weight losing
older patients with Parkinsons disease. Journal of Clinical Nursing, 15(11),
14041412.
INEFFECTIVE THERAPEUTIC REGIMEN

MANAGEMENT
DEFINITION
A pattern of regulating and integrating into daily living a program
for treatment of illness and the sequelae of illness that is unsatisfac-
tory for meeting specific health goals
Failure to include treatment regimens in daily routines
Makes choices in daily living ineffective for meeting health goals
Verbalizes desire to manage the illness
Verbalizes difficulty with prescribed regimens
RELATED FACTORS
Complexity of healthcare Economic difficulties
system Family conflict
Complexity of therapeutic Knowledge deficit
regimen Mistrust of regimen
Decisional conflicts Perceived seriousness
Healthcare system Risk management
EXPECTED OUTCOMES
The patient will
Express personal beliefs about illness and its management.
Develop a plan for integrating components of therapeutic regimen,
such as medications, activity, and diet, into pattern of daily living.
Select daily activities to meet goals of treatment or prevention
program.
Express intent to reduce risk factors for progression of illness.
Make use of available support services.
Compliance Behavior; Knowledge; Treatment Regimen; Participation
in Healthcare Decisions; Treatment Behavior; Illness or Injury
Determine: Assess health history; prescriptions for treatment, includ-
ing medications, activity, diet, and other treatments; current medica-
tion schedule (prescribed and over-the-counter); ADLs; self-care abil-
ities; and health beliefs. Information from the assessment will
provide assistance to determine appropriate goals and interventions.
Perform: Work directly with the family to establish a daily routine
for managing the therapeutic regimen that fits with their lifestyle.
This makes it possible to combine scientific knowledge of the illness
with lifestyle factors such as culture, family dynamics, and finances.
373
Inform: Educate patient about the current health issues and provide
clearly written information about the treatment regimen. Explain the
relationship between the pathophysiology and the therapeutic regi-
men. A patient who knows the reasons for specific behaviors may
be more willing to adjust his or her lifestyle.
Teach those skills that the patient must incorporate into daily liv-
ing. Have patient perform return demonstration of each skill to aid
in gaining confidence.
cognition, patients will be better prepared to cope.
Include family members in teaching. Demonstrate to family mem-
bers how each coping strategies can be used to deal with challenging
incidents. Including the family will help when the patient flounders
or cannot recall what was taught.
Attend: Promote verbal reminders to reinforce health-promoting
behaviors. For example, remind patient with heart disease to stop
smoking. Verbal cues may stimulate the patient to take action, if not
immediately, then at a later time.
Encourage family members to plan for a future course of the ill-
ness. For example, family may need to make structural changes at
home to accommodate a wheelchair or hospital beds. Planning
enhances ability of patient and family to develop appropriate man-
agement strategies.
Manage: Refer patient and family members to support groups or
self-help organizations to empower or family members to continue
effective management of the therapeutic regimen.
Behavior Modification; Decision-Making Support; Mutual Goal-
Setting; Patient Contracting
Reference
Giger, J. N., et al. (2006, spring). Multi-cultural and multi-ethnic considera-
tions and advanced directives: Developing cultural competency. Journal of
Cultural Diversity, 13(1), 39.
INEFFECTIVE FAMILY THERAPEUTIC

MANAGEMENT
DEFINITION
A pattern of regulating and integrating into the family processes a
program for treatment of illness and the sequelae of illness that is
unsatisfactory for meeting specific health goals
Acceleration of illness symptoms in a family member
Inappropriate family activities for meeting health goals
Lack of attention to illness
Verbalizes desire to manage illness
Verbalizes difficulty with therapeutic regimen
RELATED FACTORS
Complexity of healthcare Decisional conflicts
system Economic difficulties
Complexity of therapeutic Excessive demands
regimen Family conflicts
EXPECTED OUTCOMES
The family members will
Identify behaviors that lead to conflict.
Participate in family therapy sessions and openly express feelings
about illness of family member.
Express desire to receive help to resolve conflicts.
Describe understanding of coping mechanisms that resolve
conflicts.
Cooperate in finding ways to incorporate therapeutic regimen.
Express desire to carry out therapeutic regimen.
Plan for future course of illness.
Compliance Behavior; Family Coping; Family Functioning; Family
Normalization; Family Participation in Professional Care; Knowledge
Determine: Assess level of education; occupation; values and beliefs;
attitudes about health and illness; coping patterns; family status,
including marital status, family composition, communication
patterns, coping skills, drug or alcohol degree of trust in others;
beliefs and attitudes about health; socioeconomic factors; spiritual
status, including religious affiliation and description of faith and
religious practices; perceptions about life, death, and suffering.
375
Assessment information will assist in identifying appropriate
outcomes and interventions for this diagnosis.
Perform: Work directly with the family to establish a daily routine
for managing the therapeutic regimen that fits with their lifestyle.
Collaboration with patient and family members makes it possible to
combine scientific knowledge of the illness with lifestyle factors such
as culture, family dynamics, and finances.
a motivation for the parents to continue searching for information.
Direct patient to use other sources such as libraries, Internet, or
professional organizations. An independent search results in the par-
ents developing confidence in their own ability to find answers to
their questions about health and wellness.
Select teaching strategies that will enhance teaching/learning effec-
tiveness, such as discussion, demonstration, role-playing, and visual
materials.
Teach those skills that the patient must incorporate into ability to
go further pursue the area of interest.
Attend: Assist patient to set goals and develop a plan to provide
concrete direction to the patients desire to enhance the effective
management of the therapeutic regimen.
Promote verbal reminders to reinforce health-promoting behaviors.
For example, remind patient with heart disease to stop smoking.
Verbal cues may stimulate the patient to take action, if not immedi-
ately, then at a later time.
Encourage family members to plan for future course of illness.
For example, family may need to make structural changes at home
to accommodate a wheelchair or hospital beds. Planning enhances
ability of patient and family to develop appropriate management
strategies.
Encourage patient and family to verbalize feelings and concerns
related to the knowledge and skills that parents need. This promotes
greater ease in managing challenging situations.
Manage: Refer family to social and community resources for ongo-
ing assistance with parenting. Parents can contact these sources for
additional information as needed.
Case Management; Coping Enhancement; Decision-Making Support;
Family Involvement; Family Process Maintenance; Family Support
Reference
Verhaege, S., et al. (2005, September). Stress and coping among families of
patients with traumatic brain injury: A review of the literature. Journal of
READINESS FOR ENHANCED THERAPEUTIC

REGIMEN MANAGEMENT
DEFINITION
A pattern of regulating and integrating into daily living a program
for treatment of illness and its sequelae that is sufficient for meeting
health-related goals and can be strengthened
Choices of daily living that are appropriate for goals of health
Describes reduction of risk factors
Expresses desire to manage illness
Expresses little difficulty with therapeutic regimen
No unexpected acceleration of illness symptoms
Behavioral Emotional
Coping Roles/responsibility
EXPECTED OUTCOMES
The patient will
Demonstrate ability to articulate strengths and competencies in
managing therapeutic regimen.
Set goals related to enhancement of therapeutic regimen.
Identify types of support needed to enhance behaviors.
Knowledge: Treatment Regimen; Symptom Control; Treatment
Behavior; Illness or Injury
Determine: Assess level of education; occupation; values and beliefs;
attitudes about health and illness; coping patterns; family status,
including marital status, family composition, communication patterns,
coping skills, drug or alcohol degree of trust in others; beliefs and
attitudes about health; socioeconomic factors; spiritual status, includ-
ing religious affiliation and description of faith and religious practices;
perceptions about life, death, and suffering. Assessment information
will provide help in determining outcomes and interventions.
Perform: Work directly with patients family to establish a daily rou-
tine for managing therapeutic regimen that fits with their lifestyle.
Collaboration with patient and family members makes it possible to
combine scientific knowledge of the illness with lifestyle factors such
as culture, family dynamics, and finances.
Inform: Assist patient to set goals and develop a plan to provide
concrete direction to enhance the effective management of the thera-
peutic regimen.
Promote verbal reminders to reinforce health-promoting behaviors.
For example, remind patient with heart disease to stop smoking.
377
Verbal cues may stimulate the patient to take action, if not immedi-
ately, then at a later time.
Encourage family members to plan for a future course of the ill-
ness. For example, family may need to make structural changes at
home to accommodate a wheelchair or hospital beds. Planning
enhances ability of patient and family to develop appropriate man-
agement strategies.
Attend: Encourage weekly discussions about progress in parenting to
develop family unity and allow members to address problems before
they become overwhelming.
Manage: Assist family members to contact community agencies that
can assist them in their efforts to maintain enhanced therapeutic
management skills.
Decision-Making Support; Support System Enhancement
References
Schulman-Green, D. J., et al. (2006, October). Goal setting as a shared deci-
sion-making strategy among clinicians and their older patients. Patient Edu-
cation and Counseling, 63(1/2), 145151.
INEFFECTIVE THERMOREGULATION
DEFINITION
Temperature fluctuation between hypothermia and hyperthermia
Cyanotic nail beds Increased respiratory/heart rate
Fluctuations in body tempera- Mild shivering
ture outside normal ranges. Moderate pallor
Flushed skin Piloerection
Hypertension Seizures
Increased capillary refill time Warm or cool skin
RELATED FACTORS
Aging Illness
Fluctuating environmental Immaturity
temperature Trauma
Cardiac function Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain body temperature at normothermic levels.
Have no episodes of shivering.
Express feelings of comfort.
Exhibit skin that is warm and dry.
Maintain heart rate and blood pressure within normal range.
Show no signs of compromised neurologic status.
Voice an understanding of health problem.
Hydration; Thermoregulation; Vital Signs
Determine: Monitor patient's body temperature every 4 hr or more
often as indicated to determine effectiveness of therapy or if
intervention is needed. Record temperature and route (baseline data
depends on route).
Monitor and record patients neurologic status every 8 hr. Report
any changes to the physician. Hyperthermia increases cerebral edema
and thus intracranial pressure; hypothermia depresses metabolic rate.
Monitor and record patients heart rate and rhythm, blood pressure,
and respiratory rate every 4 hr. Hyperthermia may create hypoxia by
increasing oxygen demand, which results from increased tissue metabo-
lism (metabolism increases 7% with each increase of 1 F [0.6 C]).
This, in turn, results in faster breathing and a rising pulse rate.
Perform: Administer analgesics, antipyretics, and medications that
prevent shivering, as indicated. Monitor and record their
379
effectiveness. Antipyretics help reduce fever. Shivering tends to retard
the lowering of body temperature.
If patient develops excessive fever, take the following steps:
Reduce excessive fever.
Remove blankets; place a loincloth over patient.
Apply ice bags to the axilla and groin.
Initiate a tepid water sponge bath.
Use a hypothermia blanket if temperature rises above ____.
Cool patient to ____.
Maintain hydration.
Monitor intake and output.
Administer parenteral fluids, as ordered.
Maintain the environmental temperature at a comfortable setting.
Ensure that all metal and plastic surfaces that come into contact
with patients body are covered.
Make sure that linens and clothing are clean and dry.
These measures aid in reducing core temperature.
Inform: Instruct patient and family members about:
signs and symptoms of altered body temperature
precautionary measures to avoid hypothermia or hyperthermia
adherence to other aspects of healthcare management to help
normalize patients temperature (such as dietary habits and
measures to prevent increased intracranial pressure)
rationale for treatment.
These measures allow patient to take an active role in health
maintenance.
Attend: Acknowledge patients fluid preference. Keep oral fluids at
the bedside and encourage patient to drink. These measures help
maintain fluid balance and encourage patient to actively participate
in the prescribed treatment.
Manage: Make referral to community health agency, if needed, to
obtain adequate heating or cooling in home.
Bathing; Environmental Management; Fever Treatment; Fluid Manage-
ment; Fluid Monitoring; Temperature Regulation; Vital Signs Monitoring
Reference
Lasater, M. (2005, March). The role of thermoregulation in cardiac resuscita-
tion. Critical Care Nursing Clinics of North America, 17(1), 97102.
IMPAIRED TISSUE INTEGRITY

DEFINITION
Damage to mucous membranes or to corneal, integumentary, or sub-
cutaneous tissue
Damaged tissue (cornea, mucous membrane, integumentary, subcu-
taneous)
Destroyed tissue
RELATED FACTORS
Altered circulation Mechanical factors (e.g., pres-
Chemical irritants sure, shear, friction)
Fluid deficit or excess Nutritional deficit or excess
Impaired physical mobility Radiation
Knowledge deficit Temperature extremes
EXPECTED OUTCOMES
The patient will
Experience relief from immediate signs and symptoms (pain,
ulcers, color changes, and edema).
Maintain collateral circulation.
Voice intent to stop smoking.
Voice intent to follow specific management routines after
discharge.
Knowledge: Treatment Regimen; Self-Care Hygiene; Tissue Integrity:
Skin & Mucous Membranes; Tissue Perfusion: Peripheral; Wound
Healing: Secondary Intention
Determine: Monitor intake and output and record daily weight to detect
imbalances. Maintain adequate hydration. Adequate hydration reduces
blood viscosity and decreases the risk of clot formation.
Perform: Provide scrupulous foot care to prevent fungal infections
and ingrown toenails, stimulate circulation, and promote detection
of signs and symptoms to decrease tissue perfusion.
Administer and monitor treatments according to institutional
protocols. Immediately report abnormal findings to the physician.
For patient with venous insufficiency, apply antiembolism
stockings or intermittent pneumatic compression stockings, removing
them for 1 hr every 8 hr or according to institutional protocol.
381
Elevate patients feet while sitting, and elevate foot of bed 6989
(1520.5 cm) while lying down. These measures promote venous
return and decrease venous congestion in lower extremities.
For patient with arterial insufficiency, elevate the head of the bed
6989 while patient is lying down to increase arterial blood supply
to extremities.
Inform: Instruct patient to avoid pressure on popliteal space. For
example, say Dont cross your legs or wear constrictive clothing
to avoid reducing arterial blood supply and increasing venous
congestion.
Educate patient about risk factors and prevention of injury. Teaching
about factors influencing peripheral vascular disease and prevention of
tissue damage helps prevent complications.
Attend: Encourage adherence to an exercise regimen, as tolerated.
Exercise improves arterial circulation and venous return by promot-
ing muscle contraction and relaxation.
Manage: Refer patient to a smoking cessation program. Smoking
constricts vessels and contributes to reduced circulation.
Circulatory Care: Arterial Insufficiency; Circulatory Precautions;
Nutrition Management; Oral Health Maintenance; Positioning; Pres-
sure Management; Pressure Ulcer Prevention; Skin Surveillance;
Teaching: Foot Care
Reference
Bjellerup, M. (2006, November). Determining venous incompetence: A report
from a specialised leg ulcer clinic. Journal of Wound Care, 15(10), 429436.
RISK FOR DECREASED CARDIAC TISSUE

PERFUSION
DEFINITION
Risk for a decrease in cardiac (coronary) circulation
RISK FACTORS
Cardiac surgery Hypoxemia
Diabetes mellitus Hypoxia
Family history of coronary Lack of knowledge of modifi-
artery disease able risk factors (e.g., smok-
Hyperlipidemia ing, sedentary lifestyle,
Hypertension obesity)
Hypovolemia
Cardiac function
Physical regulation
EXPECTED OUTCOMES
The patient will
Not experience any signs or symptoms of decreased cardiac
tissue perfusion.
Verbalize modifiable risk factors for decreased cardiac perfusion.
Identify reportable symptoms of possible decreased cardiac
perfusion.
Knowledge: Cardiac Disease Management, Cardiac Pump Effectiveness,
Circulation Status; Tissue Perfusion: Cardiac
Determine: Assess hemodynamic status, including blood pressure, heart
rate, oxygen saturation, and respiratory rate for any abnormalities that
may be early indicators of altered perfusion.
Monitor cardiac rhythm for any irregularities that may indicate
cardiac irritability.
Perform: Assist with the preparation and completion of diagnostic
tests and the postprocedural patient care. Safe completion of
diagnostic test will result in improved patient outcomes.
Treat episodes of tachycardia promptly. Cardiac tissue is perfused
during diastole and perfusion time is decreased if tachycardia is not
treated.
Inform: Provide patient with information regarding modifiable
risk factors and interventions to minimize risks. Knowledge of
risk factors will contribute to informed decisions about lifestyle
changes.
Attend: Encourage patient and family to share concerns regarding
outcomes of tests to reduce anxiety.
383
Manage: Collaborate with other members of healthcare team to
ensure that all underlying medical conditions are being managed
effectively. This will minimize the possibility of cardiac perfusion
complications.
Risk Identification; Teaching: Disease Process; Cardiac Care; Hemo-
dynamic Regulation
References
Braun, L. T. (2006). Cardiovascular disease: Strategies for risk assessment and
modification. The Journal of Cardiovascular Nursing, 21, 2042.
McGraw, L. K., Turner, B. S., Stotts, N. A., & Drakup, K. A. (2008). A
review of cardiovascular risk factors in US military personnel. The Journal
of Cardiovascular Nursing, 23, 338344.
RISK FOR INEFFECTIVE CEREBRAL TISSUE

PERFUSION
DEFINITION
At risk for a decrease in cerebral circulation
RISK FACTORS
Abnormal prothrombin and Head trauma
partial thromboplastin times Hypertension
Atrial fibrillation Treatment side effects
Carotid stenosis (cardiopulmonary bypass,
Cerebral aneurysm medications)
Coagulopathy
Neurocognition
Sensation/perception
EXPECTED OUTCOMES
The patient will
Understand the need for frequent neurological assessments to
assess for any changes.
Experience adequate cerebral perfusion evidenced by normal neu-
rological checks.
Participate in diagnostic testing when necessary.
Verbalize strategies to minimize or decrease modifiable risk factors.
Tissue Perfusion: Cerebral; Neurological Status; Circulation Status
Determine: Assess patient for positive risk factors for decrease in cerebral
perfusion, including carotid stenosis, hypertension, coagulopathies, atrial
fibrillation, smoking. Risk factor reduction will result in positive patient
outcomes.
Perform: Facilitate completion of diagnostic tests and provide post-
procedure care to prevent complications to ensure accurate safe and
timely diagnosis and treatment.
Maintain adequate oxygenation to ensure cerebral perfusion.
Inform: Educate at-risk patients of the signs of decreased cerebral
perfusion about the importance of timely medical intervention for
positive symptoms. Change in mental status is a sensitive indicator
for decreased cerebral perfusion.
Educate patients about need for prompt intervention if signs of
stroke have occurred. Early intervention can prevent or minimize
stroke severity.
Attend: Encourage at-risk patient and family to ask questions and
share concerns to increase their confidence and ability to recognize
and respond to warning signs of decreased cerebral perfusion.
385
Manage: Collaborate with community organizations to educate pub-
lic on risk factors for and symptoms of decreased cerebral perfusion
and the appropriate response. Increased community awareness may
result in a more timely intervention for decreased cerebral perfusion
conditions.
Cerebral Perfusion Promotion; Neurologic Monitoring
Reference
Sauerbeck, L. R. (2006). Primary stroke prevention. The American Journal of
Nursing, 106, 4049.
RISK FOR INEFFECTIVE GASTROINTESTINAL

PERFUSION
DEFINITION
At risk for decrease in gastrointestinal circulation
RISK FACTORS
Abdominal aortic aneurysm Treatment side effects (e.g.,
Anemia cardiopulmonary bypass, med-
Gastric paresis (e.g., diabetes ication, anesthesia, gastric sur-
mellitus) gery)
Gastrointestinal disease (e.g., Vascular disease (e.g., periph-
duodenal or gastric ulcer, eral vascular disease, aortoiliac
ischmic colitis, ischemic pan- occlusive disease)
creatitis)
ASSESSMENT FOCUS
Cardiac function
Elimination
EXPECTED OUTCOMES
The patient will
Acknowledge the need to report any sudden increase in abdominal
pain.
Not experience any organ injury related to decrease in
gastrointestinal perfusion.
Understand the rationale and need for frequent abdominal assess-
ment.
Verbalize strategies to decrease identified, individual risk factors.
Tissue Perfusion: Abdominal Organs, Fluid Balance, Gastrointestinal
Function
Determine: Assess bowel sounds for motility. Impaired motility can cause
functional, nonmechanical obstruction, for example, ileus.
Assess abdomen for distention that can compromise blood flow
and result in ischemia.
Perform: Monitor vital signs closely and provide early intervention
for those at risk to ensure adequate gastrointestinal perfusion.
Inform: Educate patients at risk to promptly report any abdominal
pain. Abdominal pain is a sensitive, nonspecific indicator of
gastrointestinal dysfunction.
Attend: Encourage at-risk patients to ask questions and share concerns
to promote understanding and decrease anxiety.
387
Manage: Coordinate care and promote early intervention for
evidence of decreased gastrointestinal perfusion. Early intervention
will result in improved patient outcomes.
Risk Identification; Circulatory Care: Arterial Insufficiency
Reference
Martin, B. (2007). Prevention of gastrointestinal complications in the critically
ill patient. AACN Advanced Critical Care, 18, 158166.
INEFFECTIVE PERIPHERAL TISSUE

PERFUSION
DEFINITION
Decrease in blood circulation to the periphery that may compromise
health
Altered skin characteristics (e.g., hair, nails, moisture, sensation,
temperature, color, elasticity)
Blood pressure changes in extremities
Claudication
Color does not return to leg on lowering the leg
Delayed peripheral wound healing
Diminished pulses
Edema
Extremity pain
Paresthesia
Skin color pale on elevation
RELATED FACTORS
Lack of knowledge of disease process (e.g., diabetes,
hyperlipidemia)
Lack of knowledge of aggravating factors (e.g., smoking, sedentary
lifestyle, trauma, obesity, salt intake, immobility)
Comfort Sensation/perception
Self-care Tissue integrity
Cardiac function
EXPECTED OUTCOMES
The patient will
Understand the need to maintain moderate activity level to
promote circulation.
Articulate the need and rationale for smoking cessation.
Not experience ischemic damage to involved extremity.
Experience adequate perfusion to promote prompt wound healing.
Acknowledge the importance of protecting involved extremity from
injury.
Recognize reportable changes in skin characteristics to the
involved extremity that indicate decreased perfusion.
Activity Tolerance; Tissue Integrity: Skin and Mucous Membranes;
Tissue Perfusion: Peripheral
Determine: Evaluate involved extremity for clinical signs (pain, decreased
temperature, pallor, delayed capillary refill, weak or absent pulse,
389
decreased sensation, and decreased pulse oximetry) that are indicators of
ineffective peripheral perfusion.
Perform: Protect the extremity from injury using sheepskin or bed
cradle and position extremity at or lower than level of heart to pro-
mote collateral blood flow.
Inform: Instruct patient to increase walking activity to promote col-
lateral circulation and improve blood supply to extremity.
Teach patient to avoid crossing legs or keeping legs in a depend-
ent position to avoid constriction of veins.
Attend: Encourage patient to protect extremity from injury or
extreme hot or cold temperatures. Infection or ulcer formation may
develop more easily because of decreased blood supply.
Manage: Refer patients who smoke to smoking cessation program
because continued smoking will significantly increase risks for
further damage.
Circulatory Care: Arterial Insufficiency, Exercise Promotion,
Positioning, Skin Surveillance
Reference
Bonham, P. A., & Kelechi, T. (2008). Evaluation of lower extremity arterial
circulation and implications for nursing practice. The Journal of Cardiovas-
cular Nursing, 23, 144152.
RISK FOR INEFFECTIVE RENAL TISSUE

PERFUSION
DEFINITION
At risk for a decrease in blood ciruclation to the kidney that may
compromise health
RISK FACTORS
Systemic inflammatory Treatment-related side effects
response syndrome Renal artery stenosis
Hypoxia Renal disease
Hypovolemia Hypertension
Infection Diabetes mellitus
Cardiac function
Elimination
EXPECTED OUTCOMES
The patient will
Identify risk factors that contribute to risk for decreased renal per-
fusion.
Make appropriate lifestyle changes to minimize risks, including
careful management of chronic health conditions.
Verbalize signs and symptoms of possible renal dysfunction related
to impaired perfusion.
Maintain fluid balance.
Cardiac Pump Effectiveness; Electrolyte & AcidBase Balance;
Kidney Function; Knowledge: Health Promotion
Determine: Assess patient current management of preexisting health
conditions that increase the risk of decreased renal perfusion. Effec-
tive management of chronic health conditions will help preserve kid-
ney function.
Monitor intake and output to evaluate need for fluid replacement.
Perform: Collect and evaluate laboratory and urine data that may
indicate renal damage. Serum creatinine levels and urine protein and
creatinine are sensitive indicators of renal function.
Maintain mean arterial pressure of at least 6070 to provide con-
tinuous perfusion needed for optimal renal function
Inform: Provide patient teaching regarding the need to control modi-
fiable risk factors and the signs and symptoms that indicate renal
dysfunction. Prevention and early intervention are essential in main-
taining renal function.
Attend: Provide patient and family with encouragement and psycho-
logical support to reinforce positive health behaviors.
391
Manage: Collaborate with other members of the healthcare team to
develop an individualized plan of care to reduce risk factors. A mul-
tidisciplinary approach results in positive patient outcomes.
Electrolyte Monitoring; Hemodynamic Regulation
Reference
Russell, S. (2008). Responding to threats to the kidney. Nursing 2008, 38,
3640.
IMPAIRED TRANSFER ABILITY

DEFINITION
Limitation of independent movement between two nearby surfaces
Impaired ability to transfer:
Between uneven levels From standing to floor or
From bed to chair from floor to standing
From chair to car or from car In and out of tub or shower
to chair On or off a toilet or commode
From chair to floor or from
floor to chair
RELATED FACTORS
Cognitive impairment Lack of knowledge
Deconditioning Musculoskeletal impairment
Environmental constraints Neuromuscular impairment
Impaired balance Obesity
Impaired vision Pain
Insufficient muscle strength
Knowledge Pharmacological function
EXPECTED OUTCOMES
The patient will
Have no evidence of complications associated with impaired transfer
mobility, such as depression, altered health maintenance, and falls.
Achieve the highest level of mobility possible (independence with
regard to need for assistive device, verbalization of needs regarding
transfer).
Maintain safety during transfer.
Adapt to alteration in ability to perform transfer.
Demonstrate understanding of transfer techniques.
Participate in social and occupational activities to the greatest
extent possible.
Balance; Body Positioning: Self-Initiated; Joint Movement: Hip, Knee,
Spine; Knowledge: Body Mechanics; Mobility; Transfer Performance
Determine: Identify patients level of independence using the functional
mobility scale. Report findings to the staff to provide continuity and pre-
serve the documented level of independence.
altered mobility or decreased ability to perform transfer with assistive
393
device (contractures, venous stasis, skin breakdown, thrombus forma-
tion, depression, altered health maintenance, or self-care deficit).
Patients with neuromuscular dysfunction are at risk for complications.
Assess patients skin upon her return to bed. If patient is using a
wheelchair, request a seat cushion, if necessary, to maintain skin integrity.
Perform: Perform ROM exercises to the joints of affected limbs, unless
contraindicated, at least once per shift. Progress from passive to active
ROM, as tolerated, to prevent joint contractures and muscle atrophy.
Inform: Teach patient transfer techniques, such as performing a
standing or sitting transfer, to maintain muscle tone, prevent compli-
cations of immobility, and promote independence.
Adapt teaching to the limits imposed by patients condition to pre-
vent injury. As part of teaching plan, demonstrate transfer techniques
to family members to ensure that necessary adaptations are made by
family. Have patients family perform a return demonstration to
ensure the use of proper technique and to promote continuity of care.
Attend: Encourage patient to attend physical therapy. Request a
written copy of instructions for assistive device to use as a reference
to maintain continuity of care and foster safety.
Manage: Refer patient to a physical therapist for the development of
a mobility program related to assistive device to assist with rehabili-
tation of musculoskeletal deficits.
Identify resources (stroke program, sports association for disabled,
National Multiple Sclerosis Society) to promote patients reintegra-
tion into the community.
Body Mechanics Promotion; Energy Management; Exercise Promo-
tion: Strength Training; Exercise Therapy: Balance; Fall Prevention;
Self-Care Assistance: Transfer
Reference
Gavin-Dreschnack, D., et al. (AprilJune, 2005). Wheelchair-related falls: Cur-
rent evidence and directions for improved quality care. Journal of Nursing
Care Quality, 20(2), 119127.
RISK FOR TRAUMA

DEFINITION
Accentuated risk of accidental tissue injury (e.g., wound, burn,
fracture)
RISK FACTORS
Balancing difficulties Lack of safety precautions
Cognitive difficulties Poor vision
Emotional difficulties Reduced eyehand coordination
History of previous trauma Reduced muscle coordination
Insufficient finances Reduced sensation
Lack of safety education Weakness
Behavior Knowledge
Emotional
EXPECTED OUTCOMES
The patient will
Avoid injury.
Voice need for understanding safety precautions.
Demonstrate correct use of safety devices (i.e., walker or cane).
Falls Occurrence; Personal Safety Behavior; Physical Injury Severity;
Risk Control; Safe Home Environment; Tissue Integrity: Skin &
Mucous Membranes
Determine: Accident; allergies; exposure to pollutants, hyperthermia,
hypothermia, poisoning, sensory changes; seizures; level of consciousness;
clotting factors; platelet and WBC counts. Assessment will provide assis-
tance with identifying goals and interventions.
Perform: Assist with daily self-care activities such as bathing and
grooming to promote comfort.
Encourage fluids, as ordered, to moisten mucous membranes and
dilute chemical materials in the body.
Administer medication to reduce pain; monitor patient to assess
the results of the medication.
Keep bedrails raised to ensure safety. Maintain position of the bed
as low as possible to prevent the patient from falling and sustaining
further injury.
family such as meditation, guided imagery, yoga, and prayer to pre-
positive decisions.
395
techniques in carrying out usual daily activities.
care. Having the patient practice before trying independently will
inspire confidence.
Provide patient and family with information about necessary
safety precautions to enable them to take an active role in
healthcare and maintain a safe environment.
Instruct patient in the use of assistive devices to ensure their
proper use and provide the patient with a feeling of security.
Attend: Encourage patient and family to express feelings and
concerns related to trauma. Discussing feelings can be therapeutic.
Active listening conveys respect for the patient.
which they plan to enhance their coping skills in the present situa-
tion.
Manage: Refer family to community resources and support groups
Anxiety Reduction; Fluid Management; Coping Enhancement
Reference
McCarter-Boyd, A., et al. (2005, March). Preventing falls in acute care: An
innovative approach. Journal of Gerontological Nursing, 31(3), 2533.
RISK FOR VASCULAR TRAUMA

DEFINITION
At risk for damage to a vein and its surrounding tissues related to
the presence of a catheter and/or infused solutions
RISK FACTORS
Catheter width Length of insertion time
Impaired ability to visualize Infusion rate
insertion site Nature of solution (e.g., con-
Inadequate catheter fixation centration, chemical irritant,
Insertion site temperature, pH)
Tissue integrity
EXPECTED OUTCOMES
The patient will
Not experience vascular trauma as a result of catheter or infused
solution.
Communicate reportable signs and symptoms indicating possible
catheter- or infusion-related problems.
Maintain recommended position of extremity during treatment.
Tissue Integrity: Skin & Mucous Membranes; Comfort Status: Physi-
cal; Knowledge: Treatment Procedure
Determine: Assess patient for pain at insertion site. Pain is often the first
symptom of vascular trauma.
Perform: Use transparent dressing over the insertion site. This will
secure the catheter and facilitate frequent assessment of the insertion
site.
Perform prescribed insertion site checks and progress of the infu-
sion to ensure early identification of problems and timely interven-
tions to avoid vascular trauma.
Inform: Educate patient about the purpose of the infusion and
reportable symptoms indicative of trauma, for example, burning,
swelling, warmth. Prompt termination of the infusion and the
catheter will minimize damage to the tissue.
Attend: Support the patient throughout intravenous therapy to
decrease anxiety and promote positive patient outcomes.
Manage: Collaborate with experienced team members in the
management of complex intravenous therapy to ensure that all pos-
sible steps are taken to minimize complications.
397
Intravenous Therapy; Medication Administration: Intravenous; Skin
Surveillance; Teaching: Procedure/Treatment
References
Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients
with peripheral intravenous catheters: A descriptive study. Journal of the
American Academy of Nurse Practitioners, 20, 172180.
Zarate, L., Mandelco, B., Wilshaw, R., & Ravert, P. (2008). Peripheral intra-
venous catheters started in prehospital and emergency department settings.
Journal of Trauma Nursing, 15, 4752.
IMPAIRED URINARY ELIMINATION

DEFINITION
Dysfunction in urinary elimination
Dysuria Nocturia
Frequency Retention
Hesitancy Urgency
Incontinence
RELATED FACTORS
Anatomical obstruction Sensory motor impairment
Multiple causality Urinary tract infection
Coping Nutrition
Elimination Reproduction
EXPECTED OUTCOMES
The patient will
Maintain fluid balance; intake will equal output.
Voice increased comfort.
Voice understanding of treatment.
Discuss impact of urologic disorder on self and family members.
Demonstrate skill in managing urinary elimination problem.
Maintain urinary continence.
Determine: Observe patients voiding pattern. Document intake and out-
put, urine color and characteristics, and patients daily weight. Report any
changes. Accurate intake and output measurements are essential for cor-
rect fluid replacement therapy. Urine characteristics help verify diagnosis.
Observe bowel habits.
Check for constipation.
Check for fecal impaction; if present, disimpact and institute a bowel
regimen.
These measures promote comfort and prevent loss of rectal muscle tone
from prolonged distention.
Perform: Administer appropriate care for the urologic condition and
monitor progress (e.g., strain urine). Report favorable and adverse
responses to the treatment regimen. Appropriate care helps patient
recover from the underlying disorder. Reporting responses to treat-
ment allows modification of the treatment, as needed.
399
If patient requires surgery, give appropriate preoperative and post-
operative instructions and care. Accurate information allows patient
to understand the procedure and builds trust in caregivers.
Provide supportive measures, as indicated.
Administer pain medication and monitor patient to reduce pain
and assess the effects of medication.
Encourage fluids, as ordered, to moisten mucous membranes
and dilute chemical materials within the body.
Assist with general hygiene and comfort measures, as needed.
Cleanliness prevents bacterial growth and promotes comfort.
Maintain patency of catheters, drainage bags, and other urinary
elimination equipment to avoid reflux and risk of infection and
ensure the effectiveness of therapy.
Provide meatal care according to facility policy to promote clean-
liness and comfort and reduce the risk of infection.
Inform: Explain reasons for therapy and intended effects to patient
and family members to increase patients understanding and build
trust in caregivers.
If patient needs urinary diversion, prepare him or her for a change
in body appearance (instruct patient and family members how to
care for the ostomy site postoperatively). Preparation and appropri-
ate information help patient and family members cope with changes.
Explain the urologic condition to patient and family members,
including instructions on preventive measures, if appropriate.
Prepare for discharge according to individual needs. Accurate health
knowledge increases patients ability to maintain health. Involving
family members assures patient that hell be cared for.
Attend: Encourage patient to ventilate feelings and concerns related
to his or her urologic problem. Active listening conveys respect for
patient; ventilation helps pinpoint patients fears.
Manage: Refer patient to a dietitian for instructions on diet. Dietary
changes may decrease urinary infections.
Refer patient and family members to a psychiatric liaison nurse, sex
counselor, or support group, when appropriate. These resources help
patient gain knowledge of himself or herself and the situation, reduce
anxiety, and promote personal growth. Community resources usually
provide support and care not available in other healthcare agencies.
Anxiety Reduction; Fluid Management; Urinary Elimination
Management; Urinary Retention Care; Weight Management
Reference
Wilde, M. H., & Dougherty, M. C. (2006, MarchApril). Awareness of urine
flow in people with long-term urinary catheters. Journal of Wound, Ostomy
and Continence Nursing, 33(2), 164174.
READINESS FOR ENHANCED URINARY

ELIMINATION
DEFINITION
A pattern of urinary functions sufficient for meeting eliminatory
needs and can be strengthened
Amount of urine output within normal limits for age
Expresses willingness to enhance urinary elimination
Fluid intake adequate for daily needs
Positions self for emptying of bladder
Specific gravity within normal limits
Urine straw colored with no odor
Coping Nutrition
EXPECTED OUTCOMES
The patient will
Maintain urine output that is clear and straw colored with no odor.
Drink 64 ounces of noncaffeinated, nonalcoholic beverages per
day (unless contraindicated).
Maintain blood pressure in normal range.
Avoid use of nonsteroidal anti-inflammatory drugs (NSAIDs), anal-
gesics, and anticholinergics.
Express understanding of health promotion activities to enhance
urinary elimination.
Determine: Asses that weight is within established norms to prevent pres-
sure on bladder which contributes to incontinence.
Assess that blood pressure is within norms; elevated ranges con-
tribute to renal failure.
Perform: Discuss voiding and fluid intake patterns to provide a base-
line for introducing new activities.
Discuss foods that increase acidity in the urine (cranberries, meats,
eggs, whole grains, and prunes) and foods that are low in sodium.
Increased acidity in the urine impedes bacterial growth. Foods high in
sodium cause fluid retention and decreased urine output.
Discuss hygiene practices, including hand hygiene, wiping and
cleaning from front to back, and taking showers rather than baths
(females). Cleaning from front to back prevents transferring micro-
organisms from the bowel to the urinary meatus. Showering flushes
microorganisms away from the urinary meatus, preventing UTIs.
401
Inform: Teach female patient to perform Kegel exercises to strengthen
pelvic muscles and prevent development of incontinence (which
occurs in 20%-40% of elderly women).
Teach stress management techniques. Stress stimulates release of
antidiuretic hormones and interferes with sphincter relaxation, which
causes urine retention.
Explain reasons for activities that enhance urinary elimination to
patient to promote understanding and compliance.
Attend: Encourage patient to drink six to eight glasses of noncaf-
feinated, nonalcoholic, noncarbonated liquid, preferably water, per
day (unless contraindicated). 1,5002,000 ml/day promotes optimal
renal function and flushes bacteria and solutes from the urinary
tract. Caffeine and alcohol promote diuresis and may contribute to
excess fluid loss. Caffeine, alcohol, and carbonation are irritating to
the bladder wall.
Encourage patient to respond to the urge to void in a timely man-
ner. Ignoring the urge to urinate may cause incontinence.
For female patient, encourage her to void before and after inter-
course to flush microorganisms away from the urinary meatus, pre-
venting UTI; to avoid bubble baths that may cause chemical irrita-
tion to urinary meatus increasing the risk of UTI; and to wear
cotton underpants as cotton is an absorbent fabric that prevents
perineal moisture retention.
Encourage patient to participate in regular exercise, including
walking and modified sit-ups (unless contraindicated). Weak abdomi-
nal and perineal muscles weaken bladder and sphincter control.
Encourage patient to avoid NSAIDs, analgesics, and anticholinergics.
NSAIDs and analgesics impair renal blood flow. Anticholinergic drugs
inhibit relaxation of urinary sphincter and cause urine retention.
Encourage patient to stop smoking (if applicable) or refrain from
starting. Smoking contributes to renal and bladder cancer. Nicotine
is a potent vasoconstrictor.
Encourage patient to avoid exposure to petroleum, heavy metals,
asbestos, dyes, rubber, leather, ink, and paint. Exposure to carcino-
gens increases the risk of renal and bladder cancer.
Manage: Advise patient to report presence of sore throat to primary
care provider. Sore throat may be indicative of streptococcal infec-
tion, which may cause renal failure.
Urinary Elimination Management
Reference
Gonzales-Gancedo, J., & Fernandez Garcia, D. (2007, MarchApril). Care
plan in a patient with spina bifida. Case report (Spanish). Enfermia Clinica,
17(2), 9095.
URINARY RETENTION
DEFINITION
Incomplete emptying of the bladder
Bladder distention Sensation of bladder fullness
Dysuria Small, frequent voiding or no
High residual urine urine output
Overflow incontinence (contin-
uous dribbling)
RELATED FACTORS
Blockage Inhibition of reflex arc
High urethral pressure Strong sphincter
Coping Nutrition
EXPECTED OUTCOMES
The patient will
Maintain fluid balance, with intake equal to output.
Voice increased comfort with few or no complications.
Voice understanding of treatment and demonstrate skill in manag-
ing urine retention.
Have urinalysis within normal limits.
Avoid bladder distention.
Discuss impact of urologic disorder on self and family members.
Determine: Monitor intake and output and report if intake exceeds out-
put to promote adequate fluid replacement therapy.
Monitor voiding pattern. Record data on time, place, amount, and
patients awareness of micturition to establish a pattern of incontinence.
Monitor therapeutic and adverse effects of prescribed medications
for early recognition and treatment of drug reactions.
Perform: Assist with ordered bladder elimination procedure as follows:
Voiding techniques. Perform Creds or Valsalvas maneuver
every 23 hr to increase bladder pressure to pass urine. Repeat
until empty.
Intermittent catheterization. Catheterize using clean or sterile
technique every 2 hr. Record the amount voided spontaneously
and the amount obtained with catheterization.
These measures promote normal voiding, prevent infection, and help
maintain the integrity of ureterovesical function.
403
Perform catheter care according to established policy and maintain a
closed drainage system to prevent skin irritation and bacteriuria. Secure
the catheter to patients leg (female) or abdomen (male), avoiding ten-
sion on the sphincter. Anchoring the catheter prevents straining of the
bladders trigone muscle and prevents friction leading to inflammation.
Use of an indwelling urinary catheter or suprapubic catheter.
Monitor patency and avoid kinks in tubing. Keep the drainage bag
below bladder level to avoid urine reflux. Change dressings accord-
ing to facility policy. Maintain closed drainage system.
Administer pain medication, as ordered, and monitor patient to
reduce pain and assess the medications effects.
For fecal impaction, disimpact and institute a bowel regimen to
promote comfort and prevent the loss of rectal muscle tone from
prolonged distention.
If patient requires surgery, give appropriate preoperative and post-
operative instructions and care to increase patients understanding. If
he undergoes urinary diversions, prepare him for a change in body
image. Preparation and appropriate information help patient and
family members cope with changes.
Inform: Instruct patient and family members on voiding techniques to
be used at home. Provide for return demonstrations until they can
perform the procedure well. Knowledge of procedures and rationales
reduces anxiety and promotes comfort. Demonstrations may progress
through several sessions until patient can perform independently.
Attend: Encourage high fluid intake 2114 2 qt (2 L)/day, unless con-
traindicated, to moisten mucous membranes and dilute chemical mate-
rials in the body. Limit fluid intake after 7 PM to prevent nocturia.
Encourage patient and family members to share feelings and con-
cerns related to urologic problems. Ventilation helps pinpoint
patients fears and establishes an environment of trust in which
patient and family members can begin to deal with the situation.
Manage: Refer patient and family members to a psychiatric liaison
nurse, enterostomal therapist, sex counselor, support group, or home
healthcare agency, when appropriate. These resources help patient
gain knowledge of himself and his situation, reduce anxiety, and
help promote personal growth. Community resources usually
provide services not available at other healthcare agencies.
Perineal Care; Urinary Bladder Training; Urinary Catheterization:
Intermittent; Urinary Elimination Management
Reference
ODell, K. K., & Labin, L. C. (2006, MayJune). Common problems of uri-
nation in nonpregnant women: Causes, current management, and prevention
strategies. Journal of Midwifery & Womens Health, 51(3), 159173.
IMPAIRED SPONTANEOUS VENTILATION

DEFINITION
Decreased energy reserves result in an individuals inability to main-
tain breathing adequate to support life
Apprehension Increased heart rate
Decreased cooperation Increased metabolic rate
Decreased pO2 Increased pCO2
Decreased SatO2 Increased restlessness
Decreased tidal volume Increased use of accessory
Dyspnea muscles
RELATED FACTORS
Metabolic factors
Respiratory muscle fatigue
Coping Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain respiratory rate at 5 breaths/min within baseline.
Demonstrate ABG levels normal for that patient.
Indicate feelings of comfort without pain or dyspnea.
Have breathing pattern return to baseline.
Demonstrate PaO2 within normal limits as activity level increases.
Breathe spontaneously after ventilation support is withdrawn.
Anxiety Level; Endurance; Energy Conservation; Respiratory Status;
Ventilation; Vital Signs
Determine: Assess vital signs; respiratory status, including rate, rhythm
and depth of respiration. Look for nasal flaring, effectiveness of cough;
suctioning demands; sputum characteristics, including color, consistency,
amount; ABGs; hemoglobin and hematocrit. Assessment information will
help identify appropriate outcomes and interventions
Perform: Check vital signs every 15 min to 1 hr to detect tachype-
nea and tachycardia, both of which are early indicators of respira-
tory distress.
Begin oxygen support using the smallest concentration needed to
make patient comfortable. Monitor closely to avoid oxygen toxicity.
Place patient in Fowlers position to increase comfort and
facilitate adequate chest expansion and diaphragmatic excursion,
thereby decreasing the work of breathing.
405
Assist patient to progress gradually from bed rest to increased
activity to improve sense of well-being.
Monitor vital signs and ABGs closely. If respiratory status is com-
promised, return to bed rest to decrease metabolic rate and lower
oxygen demands.
Inform: Explain procedures to the patient, and describe specific sen-
sations he or she may feel during each procedure. Keeping patient
informed about what to expect and when to expect it reduces
anxiety.
Teach self-healing techniques to both the patient and the family
usual daily activities. These techniques help calm the mind, reduce
anxiety, and promote ability to cooperate with treatment regimen.
Attend: Avoid respiratory depressants such as opiates, sedatives, and
paralytics because these drugs will further depress the patients abil-
ity to breathe adequately on his or her own and have the potential
to cause respiratory arrest.
Anticipate possible complications. Keep in mind that if the patient
decompensates while on 100% fraction of inspired oxygen mask,
she may require intubation. Anticipating complications facilitates
prompt intervention.
Manage: If patient requires intubation, monitor him or her for spon-
taneous breathing and gradually wean him or her from ventilator.
Progressive weaning helps patient to adjust physiologically and emo-
tionally to increased work of breathing.
example, dietitian, social worker, clergy, mental health professional.
and scheduling follow-up appointments. These measures help give
patient and family a sense of direction and control over future care.
AcidBase Management; Airway Suctioning; Artificial Airway Man-
agement; Coping Enhancement; Mechanical Ventilation; Oxygen
Therapy; Positioning
Reference
Houseman, G., & Kelley, M. (2005, August). Early respiratory insufficiency in
the ALS patient: A case study. The Journal of Neuroscience Nursing, 37(4),
216218.
DYSFUNCTIONAL VENTILATORY WEANING

RESPONSE
DEFINITION
Inability to adjust to lowered levels of mechanical ventilator support
that interrupts and prolongs the weaning process
Agitation Expressed feelings of need for
Apprehension more oxygen
Baseline increase in respiratory Gasping breaths
rate Inability to respond to coaching
Decreased level of conscious- Increased concentration on
ness breathing
Deterioration in ABGs Slight cyanosis
Diaphoresis Wide-eyed look
RELATED FACTORS
Fear Ineffective airway clearance
History of multiple unsuccess- Insufficient trust in the nurse
ful weaning attempts Uncontrolled episodic ventila-
History of ventilator depend- tor demands
ence 4 days Uncontrolled pain
Cardiac function Knowledge
Coping Neurocognition
Communication Physical regulation
EXPECTED OUTCOMES
The patient will
Maintain respiratory rate at 5 breaths/min within baseline.
Have ABG levels normal for that patient.
Maintain stable mental and emotional status during weaning
process.
Indicate feelings of comfort without pain or dyspnea.
Have breathing pattern return to baseline.
Maintain PaO2 within normal limits as activity level increases.
Breathe spontaneously after ventilation support is withdrawn.
Anxiety Self-Control; Client Satisfaction; Technical Aspects of Care;
Depression Self-Control; Respiratory Status; Respiratory Status: Ven-
tilation; Risk control; Vital Signs
Determine: Assess vital signs; respiratory status, including rate, rhythm,
and depth of respiration. Look for nasal flaring, effectiveness of cough;
suctioning demands; sputum characteristics, including color, consistency,
407
amount; ABGs; hemoglobin and hematocrit; and respiratory effects of
medications. Assessment information will help identify appropriate
outcomes and interventions.
Perform: Check vital signs every 15 min to 1 hr to detect tachype-
nea and tachycardia, both of which are early indicators of respira-
tory distress.
Begin oxygen support by using the smallest concentration needed to
make the patient comfortable. Monitor closely to avoid oxygen toxicity.
Place patient in Fowlers position to increase comfort and
facilitate adequate chest expansion and diaphragmatic excursion,
thereby decreasing the work of breathing.
Assist patient to progress gradually from bed rest to increased
activity to improve sense of well-being.
Monitor vital signs and ABGs closely. If respiratory status is com-
promised, return to bed rest to decrease metabolic rate and lower
oxygen demands.
Inform: Explain procedures to the patient, and describe specific sen-
sations he or she may feel during each procedure. Keeping patient
informed about what to expect and when to expect it reduces anxiety.
Teach self-healing techniques to both the patient and the family,
usual daily activities. These measures help reduce the anxiety related
to respiratory problems and will be less likely to hyperventilate and
panic when he or she experiences difficulty breathing normally.
Attend: Avoid respiratory depressants such as opiates, sedatives, and
paralytics because these drugs further depress respirations and have
the potential to cause respiratory arrest that if the patient
decompensates while on 100% fraction of inspired oxygen mask, he
or she may require intubation. Anticipating complications facilitates
prompt intervention.
Explain in a firm, calm voice that you will help the patient main-
tain control. This encourages the patient to take control of his or
her behavior.
Manage: Organize family conferences to explore ways in which the
family can help support the ventilatory weaning process. Meetings
can help the family members ventilate fears in a safe environment.
AcidBase Management; Airway Management; Anxiety Reduction;
Mechanical Ventilatory Weaning
Reference
Pruitt, B. (2006, September). Weaning patients from mechanical ventilation.
Nursing, 36(9), 3641.
RISK FOR OTHER DIRECTED VIOLENCE

DEFINITION
At risk for behaviors in which an individual demonstrates that he or
she can be physically, emotionally, and/or sexually harmful to others
RISK FACTORS
Availability of weapons History of witnessing family
Body language violence
Cognitive impairment History of violence against
Cruelty to animals others
Fire setting History of antisocial behavior
History of childhood abuse Impulsivity
History of substance abuse Motor vehicle offences
History of threats of violence Neurological impairment
Suicidal behavior
Coping Risk factor management
Knowledge
EXPECTED OUTCOMES
The patient will
Maintain control over anger.
Successfully rechannel hostility into socially acceptable behaviors.
Discuss angry feelings and verbalize appropriate ways to tolerate
frustration.
Express need for long-term treatment.
Abuse Cessation; Abusive Behavior Self-Restraint; Aggression Self-
Control; Impulse Self-Control
Determine: Assess recent stressors; substance abuse history; previous
episodes of violence; reaction of family members to episodes of violence;
neurological examination; toxicology examination and blood chemistry.
Assessment information will help identify appropriate intervention.
Perform: Remove all objects from the environment that the patient
could use to harm himself or herself in order to provide safety and
protect potential victims of violence.
Administer prescribed medications to help patient control aggres-
sive behavior and remain calm. Monitor for effectiveness. When
used appropriately, medications will remove the need for physical
restraint.
409
Inform: Explain medication program to patient to promote compli-
ance. Make sure that medication is swallowed, as prescribed, to
ensure compliance and produce calmness.
Teach coping strategies and self-healing techniques to patient and
family members, including meditation, guided imagery, and prayer.
techniques in carrying out usual daily activities. These techniques
help calm the mind and promote ability to cooperate with the diffi-
culties associated with violent behavior.
Attend: Explain to patient in a firm, calm voice that you will help
him or her maintain control. Communicating a willingness to help
encourages the patient to take control of his or her behavior.
Encourage patient to begin discussing hostile feelings gradually to
help him or her develop more appropriate ways of dealing with
hostility.
Discuss situations that provoke feelings of anxiety, anger, and
powerlessness to identify areas of patient concern and to prevent
anger from being inappropriately directed at self.
Manage: Set limits on patients behavior to reinforce the expectation
that the patient will act in a responsible controlled manner.
Provide patient with telephone numbers and other information
about crisis centers, hotlines, and counselors. Alternatives may ease
anxiety about the perceived threat of long-term psychotherapy.
Anger Control Assistance; Behavior Management; Environmental
Management; Violence Prevention; Impulse Control
Reference
Nelstrop, L., et al. (2006). A systematic review of the safety and effectiveness
of restraint and seclusion as interventions for short-term management of
violence in adult psychiatric inpatient settings and emergency departments.
Worldviews on Evidence Based Nursing, 3(1), 818.
RISK FOR SELF-DIRECTED VIOLENCE

DEFINITION
At risk for behavior in which an individual demonstrates that he or
she can be physically, emotionally, and/or sexually harmful to others
RISK FACTORS
Age: 1519 years; over Family background
45 years History of multiple suicide
Behavior clues attempt
Conflictual interpersonal rela- Lack of personal resources
tionships Lack of social resources
Emotional problems Marital status
Employment problems Occupation
Engagement in autoerotic Suicidal ideation or plan
sexual acts
Behavior Risk management
Emotional Values/belief
EXPECTED OUTCOMES
The patient will
Maintain environment that is free from potential suicidal weapons.
Recover from suicidal episode.
Discuss feelings that precipitated suicide attempt.
Consult mental health professional.
Describe available resources for crisis prevention and management.
Verbalized noticed improvement in self-worth.
Impulse Self-Control; Self-Mutilation Restraint; Suicide Self-Restraint
Determine: Assess life situation; recent stressors; available support
systems; history of suicidal attempts; history of substance/alcohol abuse;
history of violence against person or property; history of antisocial behav-
ior. Assessment information will help identify appropriate intervention for
this diagnosis.
Perform: Remove all objects from the environment that the patient
could use to harm himself herself in order to provide safety and
protect potential victims of violence to self.
Administer prescribed medications to help patient control aggres-
sive behavior and remain calm. Monitor for effectiveness. When
used appropriately, medications will help reduce suicidal ideations.
Inform: Explain medication program to patient to promote compli-
ance. Make sure that the medication is swallowed, as prescribed, to
ensure compliance and produce calmness.
411
Teach coping strategies and self-healing techniques to patient and
family members, including meditation, guided imagery, and prayer.
techniques in carrying out usual daily activities. These techniques
help calm the mind and promote ability to cooperate with the diffi-
culties associated with suicidal behavior.
Attend: Use a warm, caring nonjudgmental manner to show uncon-
ditional positive regard.
Demonstrate understanding but dont reinforce denial of the pres-
ent situation because denial can mask the roots of suicidal feelings.
Listen carefully to the patient and do not challenge him or her to
communicate caring and support.
Manage: Make a short-term contract with the patient that he or she
will not harm him/herself during a specific period. Continue negoti-
ating until no evidence of suicidal ideation exists. A contract gets
the subject of suicide out in the open, places some responsibility to
the patient, and conveys acceptance of the patient as a person.
Provide patient with telephone numbers and other information
about crisis centers, hotlines, and counselors. Alternatives may ease
anxiety about the perceived threat of long-term psychotherapy.
Behavior Management: Self-Harm; Environmental Management: Vio-
lence Prevention; Impulse Control Training; Suicide Prevention
Reference
Ortiz, M. (2006, December). Staying alive! A suicide prevention overview.
Journal of Psychosocial Nursing and Mental Health Services, 44(12), 4349.
IMPAIRED WALKING
DEFINITION
Limitation of independent movement on foot
Impaired ability to:
Climb stairs Walk on uneven surfaces
Walk on an incline or a decline Walk required distances
RELATED FACTORS
Cognitive impairment Insufficient muscle strength
Deconditioning Lack of knowledge
Depressed mood Limited endurance
Environmental constraints Musculoskeletal impairment
(e.g., stairs, uneven surfaces) Neuromuscular impairment
Fear of falling Obesity
Impaired balance Pain
Impaired vision
Activity/exercise Pharmacological function
Neurocognition Physical regulation
EXPECTED OUTCOMES
The patient will
Have no evidence of complications associated with impaired walk-
ing, such as alteration in skin integrity, contractures, venous stasis,
or thrombus formation.
Achieve the highest level of ambulation possible (independence using
wheelchair, ambulation with device, ambulation without device).
Maintain safety during ambulation.
Demonstrate ability to use equipment or devices safely.
Adapt to alteration in walking.
Participate in social and occupational activities.
Demonstrate understanding of specific interventions related to cop-
ing with alteration in walking.
Utilize community resources to promote and maintain the highest
level of mobility.
Ambulation; Balance; Coordinated Movement; Endurance; Fall
Prevention Behavior; Mobility; ADLs
Determine: Identify patients level of independence using the functional
mobility scale.
Communicate the findings to the staff to provide continuity and
preserve documented level of independence.
413
altered walking, such as contractures, venous stasis, skin breakdown,
or thrombus formation. Patient with a history of neuromuscular
dysfunction is at risk for complications.
Perform: Perform ROM exercises for joints of affected limbs, unless
contraindicated, at least once per shift. Progress from passive to active
ROM, as tolerated, to prevent joint contractures and muscle atrophy.
Make sure that patient maintains anatomically correct and func-
tional body positioning. Proper positioning relieves pressure, thereby
preventing skin breakdown and fluid accumulation in dependent
extremities. Encourage repositioning every 2 hr when patient is in
bed to decrease pressure. Establish a turning schedule for dependent
patients to provide a method for checking on position changes.
Implement a preambulation program (e.g., turning in bed, sitting
on the side of the bed, sitting up in a chair) to increase
independence and patients self-esteem.
Perform the indicated medical regimen to manage or prevent com-
plications (e.g., administration of prophylactic heparin for venous
thrombosis) to promote patients health and well-being.
Provide progressive ambulation up to the limits imposed by
patients condition to maintain muscle tone and prevent
complications associated with immobility.
Inform: Instruct patient and family members in ambulation
techniques and measures to prevent complications to help prepare
patient and family for discharge.
Demonstrate ambulation regimen and note the date. Have patient
and family members perform a return demonstration to ensure con-
tinuity of care and use of proper technique.
Attend: Encourage attendance at physical therapy sessions and rein-
force prescribed activities by using the same equipment, devices, and
techniques used in therapy sessions. Request a written copy of
patients ambulation program to use as a reference. These measures
maintain continuity and help ensure patients safety.
Manage: Refer patient to a physical therapist for development of a
program to promote walking to assist with rehabilitation of muscu-
loskeletal deficits.
Assist in identifying resources, such as a community stroke program,
sports associations for the disabled, or the National Multiple Sclerosis
Society, to promote patients reintegration into the community.
Energy Management; Exercise Promotion: Strength Training; Exer-
cise Therapy: Ambulation; Self-Care Assistance
Reference
Watters, C. L., & Moran, W. P. (2006, MayJune). Hip fracturesA joint
effort. Orthopedic Nursing, 25(3), 157165.
WANDERING
DEFINITION
Meandering, aimless, or repetitive locomotion that exposes the indi-
vidual to harm; frequently incongruent with boundaries, limits, or
obstacles
Following behind or shadowing caregivers locomotion
Frequent or continuous movement from place to place, often revis-
iting same destinations
Fretful or haphazard locomotion or pacing
Inability to locate significant landmarks in a familiar setting
Locomotion into private or unauthorized places
Locomotion resulting in unintended leaving of a premise
Locomotion that cant easily be dissuaded or redirected
Persistent locomotion in search of missing or unattainable peo-
ple or places
RELATED FACTORS
Cognitive impairment Premorbid behavior
Cortical atrophy Sedation
Physiological state or need Separation from familiar
(hunger, thirst, pain, urination, people and places
constipation) Time of day
Activity/exercise Communication
Emotional Coping
Cardiac function Sensation/perception
Comfort Neurocognition
EXPECTED OUTCOMES
The patient will
Participate in physical or other __________ (specify) activities to
minimize wandering behavior.
Ambulate safely.
Not have unplanned exits or elopements.
The patient and the family will
Anticipate patients wandering behavior or ambulation patterns
and provide gratification before onset of wandering behavior.
Identify factors that contribute to wandering behaviors.
Personal Safety Behavior; Safe Home Environment; Ambulation
415
Determine: Assess characteristics of wandering behavior, to determine
severity of problem and plan interventions.
Assess reasons for specific behavior problems to determine possi-
ble triggers for wandering behaviors.
Determine how family members or partner handles wandering
behavior to provide a comprehensive database for planning care.
Assess patients hobbies and previous social, leisure, and exercise
activities and patterns to assist in planning interventions.
Perform: Provide safe and structured daily routine (including regular
exercise, walking, and ROM exercises) and environment to decrease
wandering behavior and minimize caregiver stress.
Avoid using physical or chemical restraints to control patients
wandering behavior. Restraints may increase agitation, anxiety, sen-
sory deprivation, falls, and wandering behavior.
Check patient for hunger, thirst, discomfort, or need for toileting.
These needs may precipitate wandering.
Inform: Instruct patient and/or family about the following:
Use dead bolt locks on doors and keep a key accessible for
quick exit to prevent unplanned exits and facilitate entrance
and exit in emergency situations.
Use fences and hedges around patios or yards and lock gates to
prevent unsafe exits.
Install electronic devices with buzzers or bells to alert others
when door or window is open.
Attend: Encourage participation in activities (e.g., dancing) and sim-
ple household chores (e.g., raking leaves, folding laundry) to reduce
anxiety and restlessness.
Manage: Notify neighbors, local police department, and staff in
retirement communities about patients condition. Keep a list of
neighbors names and phone numbers handy. Awareness by others
can prevent patient from becoming lost or injured.
Utilize community resources, such as the Alzheimers Associations
Safe Return Program, to assist in identification, location, and return
of individuals with disorders characterized by wandering behaviors.
Activity Therapy; Surveillance: Safety; Environmental Management:
Safety; Home Maintenance Management
Reference
Harada, T., Ishizaki, F., Nitta, Y., Shimorhara, A., Tsukue, I., Wu, X., et al.
(2008, March). Microchips will decrease the burden on the family of elderly
people with wandering dementia. International Medical Journal, 15(1),
2527.
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PA R T T W O
Selected Nursing
Diagnoses by Medical
Diagnosis
417
418 Part Two / Selected Nursing Diagnoses by Medical Diagnosis
Abnormal rupture of Ineffective sexuality patterns

membranes Ineffective therapeutic regi-
Deficient fluid volume men management
Hyperthermia Moral distress
Risk for infection Powerlessness
Readiness for enhanced com-
Abortion
munication
Chronic sorrow
Risk for caregiver role strain
Complicated grieving
Risk for complicated grieving
Ineffective tissue perfusion
Risk for compromised human
(specify)
dignity
Moral distress
Risk for contamination
Risk for complicated grieving
Risk for infection
Risk for loneliness
Abruptio placentae Risk-prone health behavior
Acute pain Social isolation
Anxiety
Acute pancreatitis
Acute pain
Deficient knowledge (specify)
Readiness for enhanced hope
Insomnia
Readiness for Enhanced Self-
Nausea
Concept
Risk for imbalanced nutri-
Acoustic neuroma tion: more than body require-
Chronic pain ments
Disturbed sensory perception Risk for impaired liver func-
(auditory) tion
Imbalanced nutrition: less Risk for unstable glucose
than body requirements level
Impaired skin integrity Risk-prone health behavior
Ineffective breathing pattern
Acute renal failure
Death anxiety
(cerebral)
Decreased cardiac output
Insomnia
Deficient fluid volume
Risk for deficient fluid
Disturbed thought processes
volume
Dressing or grooming self-
Acquired immunodeficiency care deficit
syndrome Excess fluid volume
Caregiver role strain Fear
Chronic confusion Impaired physical mobility
Death anxiety Impaired skin integrity
Defensive coping Ineffective tissue perfusion
Grieving (renal)
Hopelessness Interrupted family processes
Impaired memory Risk for acute confusion
Ineffective community coping Risk for complicated
Ineffective denial grieving
Ineffective protection Risk for infection
419
Risk-prone health behavior Risk for aspiration
Sexual dysfunction Risk for infection
Sleep deprivation Risk for suffocation
Spiritual distress
Acute respiratory distress
syndrome Adrenal insufficiency
Anxiety Acute pain
Bathing or hygiene self-care Chronic low self-esteem
deficit Compromised family coping
Deficient fluid volume Disturbed body image
Denial Hypothermia
Dysfunctional ventilatory Readiness for enhanced self-
weaning response care
Fear Risk for imbalanced body
Imbalanced nutrition: less temperature
than body requirements Risk for impaired skin
Impaired gas exchange integrity
Impaired skin integrity Risk for infection
Impaired spontaneous venti- Risk-prone health behavior
lation Sexual dysfunction
Impaired verbal communica- Sleep deprivation
tion
Adrenocortical insufficiency
Ineffective airway clearance
Risk for disproportionate
growth
Ineffective coping
Ineffective tissue perfusion Affective disorders
(cardiopulmonary) Anxiety
Insomnia Disturbed sensory perception
Risk for acute confusion (specify)
Risk for infection Disturbed thought processes
Hopelessness
Acute respiratory failure
Impaired religiosity
Activity intolerance
Ineffective coping
Death anxiety
Ineffective role performance
Insomnia
Denial
Readiness for enhcnced
Disturbed sensory perception
coping
Risk for loneliness
Fear
Risk for other-directed vio-
Impaired gas exchange
lence
Impaired verbal communica-
Risk-prone health behavior
tion
Sexual dysfunction
Stress overload
(cardiopulmonary)
Insomnia Alcohol addiction and abuse
Powerlessness Acute confusion
Readiness for enhanced spiri- Bathing or hygiene self-care
tual well-being deficit
Risk for acute confusion Defensive coping
Deficient knowledge (specify) Imbalanced nutrition: less

Dysfunctional family than body requirements
processes: alcoholism Impaired environmental
Functional urinary inconti- interpretation syndrome
nence Impaired home maintenance
Imbalanced nutrition: less Impaired memory
than body requirements Impaired verbal communica-
Impaired physical mobility tion
Ineffective community thera- Ineffective coping
peutic regimen management Ineffective health mainte-
Ineffective coping nance
Ineffective denial Ineffective role performance
Ineffective family therapeutic Ineffective sexuality patterns
regimen management Interrupted family processes
Insomnia Moral distress
Powerlessness Readiness for enhanced
Readiness for enhanced family knowledge
coping Readiness for enhanced self-
Readiness for enhanced family care
processes Relocation stress syndrome
Risk for acute confusion Risk for caregiver role strain
Risk for compromised human Risk for compromised human
dignity dignity
Risk for poisoning Risk for injury
Risk for self-directed violence Risk for poisoning
Risk-prone health behavior Risk for trauma
Sexual dysfunction Social isolation
Sleep deprivation Stress urinary incontinence
Social isolation
Stress overload Amniotic fluid embolism
Alzheimers disease (cardiopulmonary)
Adult failure to thrive Risk for injury
Anxiety
Amputation
Bathing or hygiene self-care
Acute pain
deficit
Chronic low self-esteem
Bowel incontinence
Chronic pain
Caregiver role strain
Decisional conflict
Chronic confusion
Delayed surgical recovery
Denial
Compromised family coping
Disturbed body image
Energy field disturbance
Grieving
Readiness for enhanced self-
Functional urinary inconti-
care
nence
Grieving
dignity
Hopelessness
421
Risk for injury Ineffective tissue perfusion
Risk-prone health behavior (cardiopulmonary)
Risk for infection
Amyotrophic lateral sclerosis
Bowel incontinence Angina pectoris
Caregiver role strain Acute pain
Chronic low self-esteem Anxiety
Complicated grieving Deficient knowledge (specify)
Compromised family coping Impaired environmental
Death anxiety interpretation syndrome
Dressing or grooming self- Ineffective denial
care deficit Ineffective role performance
Dysfunctional ventilatory Ineffective sexuality patterns
weaning response Stress overload
Grieving Anorexia nervosa
Hopelessness Anxiety
Impaired physical mobility Constipation
Impaired skin integrity Deficient fluid volume
Impaired spontaneous venti- Disturbed body image
lation Hyperthermia
Impaired verbal communica- Imbalanced nutrition: less
tion than body requirements
Ineffective airway clearance Ineffective denial
Ineffective breathing pattern Interrupted family processes
Ineffective coping Readiness for enhanced nutri-
Ineffective health maintenance tion
Ineffective sexuality patterns Risk for constipation
Readiness for enhanced Risk-prone health behavior
knowledge Sleep deprivation
Risk for aspiration Social isolation
Risk for caregiver role strain Spiritual distress
Risk for infection Stress overload
Social isolation
Antisocial personality
Anaphylactic shock disorder
(cardiopulmonary) Dysfunctional family
processes: alcoholism
(renal) Impaired home maintenance
Anemias Ineffective coping
Activity intolerance Ineffective role performance
Adult failure to thrive Readiness for enhanced
Decreased cardiac output religiosity
Fatigue Risk for other-directed violence
Impaired gas exchange Risk for self-mutilation
Impaired skin integrity Risk for suicide
Ineffective breathing patterns Sexual dysfunction
Ineffective protection Social isolation
Anxiety disorder Deficient knowledge (specify)

Anxiety Risk for decreased cardiac
Caregiver role strain tissue perfusion
Constipation
Aortic stenosis
Defensive coping
Diarrhea
Risk for decreased cardia
Hopelessness
tissue perfusion (cardiopul-
Imbalance nutrition: more
monary)
than body requirements Appendicitis
Impaired home maintenance Acute pain
Ineffective denial Imbalanced nutrition: less
Interrupted family processes than body requirements
Posttrauma syndrome Risk for infection
Powerlessness
Readiness for enhanced com- Arterial insufficiency
munication Impaired tissue integrity
Readiness for enhanced coping Arterial occlusion
Readiness for enhanced nutri- Acute pain
tion Deficient knowledge (specify)
Readiness for enhanced self- Disturbed sensory perception
concept (tactile)
Readiness for enhanced sleep Impaired skin integrity
Risk for imbalanced nutri- Ineffective tissue perfusion
tion: more than body require- (peripheral)
ments Risk-prone health behavior
Risk for impaired religiosity
Risk for loneliness Asphyxia
Risk for posttrauma syndrome Delayed growth and develop-
Sleep deprivation ment
Social isolation Hypothermia
Stress overload Ineffective breathing pattern
Risk for aspiration
Aortic aneurysm Risk for suffocation
Acute pain
Excess fluid volume Asthma
Impaired gas exchange Activity intolerance
Risk for decreased cardiac Anxiety
tissue perfusion Deficient knowledge (specify)
Risk for ineffective cerebral Dressing or grooming self-
tissue perfusion care deficit
Ineffective tissue perfusion Impaired gas exchange
peripheral for renal Impaired oral mucous mem-
brane
Aortic insufficiency Ineffective airway clearance
Activity intolerance Ineffective breathing pattern
Decreased cardiac output Ineffective coping
423
Ineffective therapeutic regi- Stress overload
men management Unilateral neglect
Latex allergy response
Benign prostatic hypertrophy
Readiness for enhanced family
coping
Impaired urinary elimination
Readiness for enhanced
Ineffective sexuality patterns
knowledge
Sexual dysfunction
Readiness for enhanced ther-
Urinary retention
apeutic regimen management
Risk for infection Bipolar disorder: Depressive
Risk for latex allergy response phase
Risk-prone health behavior Chronic low self-esteem
Stress overload Constipation
Atelectasis
Disturbed sleep pattern
Anxiety
Feeding self-care deficit
deficit
Hopelessness
Imbalanced nutrition: less
Impaired physical mobility
than body requirements
Ineffective coping
Ineffective denial
Attention-deficit/ Ineffective health mainte-
hyperactivity disorder nance
Interrupted family processes Insomnia
Readiness for enhanced family Risk for compromised human
processes dignity
Risk for delayed development Risk for injury
Stress overload Risk for self-directed violence
Sexual dysfunction
Autism Sleep deprivation
Delayed growth and develop-
Social isolation
ment Spiritual distress
Risk for delayed development
Stress overload
Risk for self-mutilation
Bipolar disorder: Manic phase
Bells palsy Chronic low self-esteem
Anxiety
Disturbed sleep pattern
(gustatory) Impaired home maintenance
Impaired swallowing
tion tion
Ineffective coping
Ineffective denial
dignity Insomnia
Social isolation
Risk for injury
Risk for other-directed vio- Impaired physical mobility

lence Impaired tissue integrity
Borderline personality
Sexual dysfunction
disorder
Bladder cancer Chronic low self-esteem
Acute pain Fear
Fear Impaired religiosity
Impaired tissue integrity Ineffective coping
Impaired urinary elimination Risk for self-directed violence
Readiness for enhanced self- Risk for self-mutilation
care Social isolation
Bowel fistula
dignity
Risk for deficient fluid vol-
Urge urinary incontinence
ume
Blindness
Bowel resection
Deficient diversional activity
Delayed surgical recovery
Deficient knowledge
Risk for infection
(specify)
Disturbed body image Brain abscess
Disturbed sensory perception Acute pain
(visual) Decreased intracranial adap-
Fear tive capacity
Impaired physical mobility Disturbed body image
Powerlessness Impaired physical mobility
Risk for injury Impaired skin integrity
Risk for loneliness Ineffective sexuality patterns
Bone marrow transplantation
(cerebral)
Risk for aspiration
Risk for ineffective cerebral
Contamination
tissue perfusion
Risk for injury
Risk for urge urinary inconti-
Diarrhea
nence
Excess fluid volume Brain tumors
Grieving Acute confusion
Imbalanced nutrition: less Bowel incontinence
than body requirements Constipation
Impaired oral mucous mem- Decreased intracranial adap-
brane tive capacity
Impaired skin integrity Disturbed sensory perception
Ineffective protection Disturbed thought processes
Risk for infection Fear
Grieving
Bone sarcomas
Impaired environmental
interpretation syndrome
Acute pain
Impaired tissue integrity
425
Impaired urinary elimination Interrupted family processes
Impaired verbal communica- Risk for constipation
tion Sleep deprivation
Ineffective coping Social isolation
Ineffective thermoregulation
Burns
Risk for injury
Acute pain
Total urinary incontinence
Constipation
Breast cancer Deficient diversional activity
Acute pain Deficient fluid volume
Anxiety Disabled family coping
Complicated grieving Disturbed body image
Decisional conflict (specify) Dysfunctional ventilatory
Deficient knowledge (specify) weaning response
Disturbed body image Grieving
Fear Hyperthermia
Grieving Hypothermia
Impaired skin integrity Imbalanced nutrition: less
Ineffective coping than body requirements
Risk for compromised human Impaired physical mobility
dignity Impaired skin integrity
Spiritual distress Impaired spontaneous venti-
lation
Breast engorgement Ineffective breathing pattern
Acute pain
Impaired skin integrity
(renal)
Ineffective breast-feeding
Powerlessness
Risk for infection
Bronchiectasis Readiness for enhanced self-
Compromised family coping care
Deficient knowledge Risk for deficient fluid vol-
Imbalanced nutrition: less ume
than body requirements Risk for imbalanced body
Impaired gas exchange temperature
Ineffective airway clearance Risk for infection
Ineffective breathing pattern Risk for injury
Risk for infection
Cancer
Bulimia nervosa Adult failure to thrive
Anxiety Chronic sorrow
Constipation Death anxiety
Deficient fluid volume Disabled family coping
Disturbed body image Energy field disturbance
Hyperthermia Grieving
Imbalanced nutrition: less Ineffective health maintenance
than body requirements Readiness for enhanced
Imbalanced nutrition: more knowledge
than body requirements Readiness for enhanced reli-
Ineffective denial giosity
Readiness for enhanced self- Risk for peripheral neurovas-

concept cular dysfunction
Readiness for enhanced spiri-
Cataracts
tual well-being
Risk for infection
Risk for spiritual distress
(visual)
Cardiac arrhythmias Impaired physical mobility
Decreased cardiac output Ineffective coping
Excess fluid volume Ineffective health maintenance
Fear Risk for injury
Cellulitis
Acute pain
(cardiopulmonary) Anxiety
Risk for ineffective cardiac
Deficient knowledge
tissue perfusion (specify)
Risk for sudden infant death
syndrome Impaired skin integrity
Stress overload
Cerebral aneurysm
Cardiac disease: End-stage Decreased intracranial adap-
Activity intolerance tive capacity
Adult failure to thrive Impaired physical mobility
Caregiver role strain Impaired skin integrity
Death anxiety Ineffective airway clearance
Decisional conflict Ineffective breathing pattern
Decreased cardiac output Ineffective tissue perfusion
Defensive coping Risk for injury
Excess fluid volume
Grieving Cerebral edema
Hopelessness Decreased intracranial adap-
Ineffective coping tive capacity
Risk for caregiver role strain Ineffective thermoregulation
Risk for infection Cerebral palsy
Risk for injury Delayed growth and develop-
Sedentary lifestyle ment
Spiritual distress Impaired physical mobility
Situational low self-esteem Readiness for enhanced self-
Cardiogenic shock care
Decreased cardiac output Risk for caregiver role strain
Excess fluid volume Risk for compromised human
Impaired gas exchange dignity
Ineffective tissue perfusion Toileting self-care deficit
Carpal tunnel syndrome
Acute pain
Cervical cancer
Acute pain
Fatigue
(peripheral)
Fear
427
Impaired skin integrity Chlamydia
Risk-prone health behavior Ineffective sexuality patterns
Risk for infection
Chemotherapy
Constipation Chloride imbalance
Deficient diversional activity Imbalanced nutrition: less
Deficient fluid volume than body requirements
Diarrhea
Cholecystitis
Acute pain
(auditory)
Risk for impaired liver func-
Impaired oral mucous mem-
tion
brane
Risk for infection
Ineffective protection Chronic bronchitis
Ineffective tissue perfusion Activity intolerance
Nausea Deficient knowledge (specify)
Readiness for enhanced Fatigue
nutrition Fear
Risk for impaired skin Hopelessness
integrity Impaired gas exchange
Risk for infection Impaired spontaneous venti-
Sexual dysfunction lation
Spiritual distress add to Ineffective airway clearance
chemo. Ineffective breathing pattern
Risk for infection
Chest trauma
Dysfunctional ventilatory Chronic fatigue syndrome
weaning response Acute pain
Impaired spontaneous venti- Fatigue
lation Hopelessness
Ineffective airway clearance Ineffective therapeutic regi-
Ineffective breathing pattern men management
Risk for aspiration Readiness for enhanced ther-
apeutic regimen management
Child abuse
Sleep deprivation
ment Chronic obstructive
Impaired parenting pulmonary disease
Readiness for enhanced par- Activity intolerance
enting Adult failure to thrive
Risk for impaired parenting Anxiety
Childbirth
Defensive coping
Interrupted family processes
Readiness for enhanced par-
enting
Dysfunctional ventilatory Interrupted family processes

weaning response Powerlessness
Fatigue Risk for impaired skin
Fear integrity
Hopelessness Risk for infection
Imbalance nutrition: more Sexual dysfunction
Cirrhosis
Impaired home maintenance
brane
Impaired spontaneous venti-
Interrupted family processes:
lation
alcoholism
Moral distress
tion
tion
Risk for impaired skin
Ineffective denial
integrity
Ineffective health maintenance
Risk for injury
Stress urinary incontinence
(cardiopulmonary)
Insomnia Cleft lip or palate
Powerlessness Compromised family coping
Risk for decreased cardiac Imbalanced nutrition: less
tissue peerfusion than body requirements
Readiness for enhanced coping Impaired verbal communica-
Risk for infection tion
Risk for injury Ineffective breast-feeding
Risk for suffocation Ineffective infant feeding pat-
Sleep deprivation tern
Risk for aspiration
Chronic pain
dignity
Chronic pain
Defensive coping Colic
Hopelessness Disorganized infant
Risk-prone health behavior behavior
Chronic renal failure Colitis
Compromised family coping Acute pain
Death anxiety Deficient fluid volume
Deficient knowledge (specify) Diarrhea
Disturbed body image Disturbed body image
Excess fluid volume Imbalanced nutrition: less
Ineffective denial than body requirements
Ineffective tissue perfusion Risk for imbalanced body
(renal) temperature
429
Risk for ineffective tissue per- Coronary artery disease
fusion (gastrointestinal [GI]) Activity intolerance
Risk-prone health behavior Acute pain
Anxiety
Colon and rectal cancer Decreased cardiac output
Acute pain
Anxiety
Health-seeking behaviors
Constipation
Diarrhea
Fear
Colostomy Ineffective tissue perfusion
Complicated grieving (cardiopulmonary)
Deficient fluid volume Risk for injury
Disturbed body image Risk-prone health behavior
Imbalanced nutrition: less Sedentary lifestyle
than body requirements Stress overload
Cor pulmonale
Ineffective tissue perfusion (GI)
Excess fluid volume
Fatigue
care Grieving
Hopelessness
dignity Impaired gas exchange
Spiritual distress
Conduct disorder Ineffective coping
Chronic low self-esteem Risk for infection
Hopelessness
Craniotomy
Acute pain
Congenital anomalies Bathing or hygiene self-care
Disabled family coping deficit
Readiness for enhanced Decreased intracranial adap-
coping tive capacity
Total urinary incontinence Delayed surgical recovery
Congenital heart disease Disturbed sensory perception
Activity intolerance Impaired physical mobility
Decreased cardiac output Impaired skin integrity
Ineffective breathing Ineffective airway clearance
pattern Ineffective breathing pattern
Interrupted family processes Ineffective tissue perfusion
Risk for disproportionate (cerebral)
growth Risk for infection
Risk for infection Sleep deprivation
Risk for injury
Crohns disease Risk for deficient fluid

Acute pain volume
Anxiety Risk for imbalanced body
Compromised family coping temperature
Deficient fluid volume Risk for imbalanced fluid
Deficient knowledge (specify) volume
Diarrhea Risk for infection
Fear
Cystitis
Acute pain
Noncompliance
Insomnia
Overflow urinary inconti-
Nausea
Pain, acute
nence
nence
Sleep deprivation
care
Risk for imbalanced fluid
volume Deafness
Risk for infection Chronic low self-esteem
Stress overload Defensive coping
Cushings syndrome
(auditory)
Fear
tion
Ineffective coping
Excess fluid volume
Readiness for enhanced coping
Hopelessness
Risk for injury
than body requirements Delusional disorder
Impaired skin integrity Disturbed thought processes
Ineffective coping Impaired home maintenance
Risk for acute confusion
Risk for imbalanced body Dementia
temperature Activity intolerance
Acute confusion
Cystic fibrosis Caregiver role strain
Activity intolerance Chronic confusion
Compromised family coping Disturbed thought
Deficient diversional activity processes
Deficient fluid volume Diversional activity deficit
Imbalanced nutrition: less Functional urinary inconti-
than body requirements nence
Impaired gas exchange Impaired environmental
Ineffective airway clearance interpretation syndrome
Ineffective breathing pattern Impaired memory
Parental role conflict Impaired verbal communica-
Risk for delayed development tion
431
Interrupted family processes Disturbed sensory perception
Risk for loneliness (visual)
Powerlessness Risk for injury
Risk for injury
Developmental disorder
Risk for self-directed violence
Disabled family coping
Social isolation
Risk for impaired parent
Depression infantchild attachment
Adult failure to thrive Risk for injury
Caregiver role strain Risk for self-mutilation
Diabetes insipidus
Constipation
brane
Fatigue
ume
nence Risk for imbalanced body
Hopelessness
temperature
Risk for unstable glucose
than body requirements level
than body requirements Diabetes mellitus
Impaired home maintenance Chronic low self-esteem
Ineffective coping Compromised family coping
Ineffective denial Constipation
Posttrauma syndrome Decreased cardiac output
Powerlessness Deficient knowledge (specify)
Readiness for enhanced hope Disturbed body image
Readiness for enhanced nutri- Disturbed sensory perception
tion Grieving
Readiness for enhanced self- Hopelessness
concept Hyperthermia
Risk for constipation Imbalance nutrition: more
Risk for imbalanced nutri- than body requirements
tion: more than body require- Impaired oral mucous mem-
ments brane
Risk for injury Impaired skin integrity
Risk for loneliness Impaired urinary elimination
Risk for poisoning Ineffective coping
Risk for posttrauma syndrome Ineffective health mainte-
Risk for self-directed violence nance
Sexual dysfunction Ineffective sexuality patterns
Sleep deprivation Ineffective therapeutic regi-
Social isolation men management
Spiritual distress Ineffective tissue perfusion
(peripheral)
Detached retina Ineffective tissue perfusion
Acute pain (renal)
Anxiety Noncompliance
Powerlessness Disseminated intravascular

Readiness for enhanced fluid coagulation
balance Decreased cardiac output
Readiness for enhanced nutri- Deficient fluid volume
tion Fear
Readiness for enhanced uri- Impaired gas exchange
nary elimination
Dissociative disorder
Risk for deficient fluid
volume
Risk for imbalanced body
temperature
Risk for imbalanced nutri- Diverticulitis
tion: more than body require- Acute pain
ments Constipation
Risk for impaired skin Deficient fluid volume
integrity Diarrhea
Risk for infection Imbalanced nutrition: less
Risk for injury than body requirements
level Down syndrome
Risk-prone health behavior Compromised family coping
Social isolation Deficient knowledge (specify)
Total urinary incontinence Delayed growth and develop-
ment
Diabetic ketoacidosis Interrupted family processes
Deficient fluid volume Readiness for enhanced
Disturbed thought knowledge
processes Readiness for enhanced self-
Risk for acute confusion care
Risk for imbalanced body Risk for aspiration
temperature Risk for delayed development
Risk for unstable glucose Risk for infection
level Risk for injury
Diarrhea
Toileting self-care deficit
Diarrhea Drug addiction
Disturbed body image Acute confusion
Readiness for enhanced fluid Adult failure to thrive
balance Decisional conflict
Risk for deficient fluid vol- Defensive coping
ume Dysfunctional family processes:
Risk for imbalanced fluid vol- alcoholism
ume Ineffective community thera-
peutic regimen management
Digoxin toxicity
Ineffective coping
Ineffective denial
Deficient knowledge
Ineffective family therapeutic
(specify)
regimen management
Risk for poisoning
433
Ineffective health mainte- Imbalanced nutrition: less
nance than body requirements
Moral distress Posttrauma syndrome
Risk for compromised human Risk for loneliness
dignity
Ectopic pregnancy
Acute pain
tion
Risk for poisoning
Risk for self-directed violence
(cardiopulmonary)
syndrome Emphysema
Sexual dysfunction Activity intolerance
Sleep deprivation Deficient knowledge (specify)
Fatigue
Drug overdose
Fear
Hopelessness
nence
Hyperthermia
Hypothermia
lation
Ineffective coping
Moral Distress
Noncompliance
Risk for infection
dignity
Risk for poisoning Empyema
Risk for suffocation Deficient fluid volume
Risk for trauma Impaired gas exchange
Spiritual distress Ineffective breathing pattern
Risk for infection
Drug toxicity
Functional urinary inconti- Encephalitis
nence Activity intolerance
Hyperthermia Acute pain
Hypothermia Anxiety
Impaired gas exchange Constipation
Risk for poisoning Deficient fluid volume
Duodenal ulcer
ment
Acute pain
Anxiety
Hyperthermia
Ineffective coping
Eating disorders (anorexia Risk for infection
nervosa and bulimia nervosa)
Endocarditis
Decisional conflict
Anxiety
Contamination Risk for impaired skin

Decreased cardiac output integrity
Deficient knowledge Risk for shock
(specify)
Failure to thrive
Excess fluid volume
ment
Risk for infection
Disorganized infant behavior
Endometrial cancer Imbalanced nutrition: less
Acute pain than body requirements
Fear Impaired parenting
Grieving Ineffective community coping
Impaired tissue integrity Risk for deficient fluid volume
Risk for disorganized infant
Endometriosis behavior
Anxiety
Risk for impaired parenting
Deficient knowledge (specify) Fetal alcohol syndrome
Grieving Compromised family coping
Risk for infection Delayed growth and develop-
Sexual dysfunction ment
Spiritual distress Disorganized infant behavior
Dysfunctional family processes:
Esophageal cancer alcoholism
Acute pain
Impaired parenting
Fatigue
Ineffective community coping
Fear
Moral distress
than body requirements Risk for disproportionate
Risk for aspiration
growth
ume Food poisoning
Risk for infection Contamination
Diarrhea
Esophageal fistula Disturbed sensory perception
(visual)
than body requirements Hyperthermia
Risk for aspiration
ume tion
Esophageal varices Ineffective breathing pattern
Deficient fluid volume Nausea
Dysfunctional family processes: Risk for infection
alcoholism Fractures
than body requirements Acute pain
deficit
ume
435
Compromised family coping Ineffective sexuality patterns
Deficient diversional activity Powerlessness
Deficient fluid volume Risk for infection
Disturbed sensory perception Risk for loneliness
Hopelessness Risk-prone health behavior
Impaired parenting Social isolation
Gestational diabetes
Risk for infection
Ineffective denial
level
self-care Gestational hypertension
Risk for constipation Activity intolerance
Risk for disuse syndrome Acute pain
Risk for falls Deficient fluid volume
Risk for infection Deficient knowledge (specify)
Risk for injury Disturbed sensory perception
Risk for peripheral neurovas- (visual)
cular dysfunction Excess fluid volume
Risk for trauma Fear
Gall bladder disease
(cerebral)
Acute pain
Readiness for enhanced child-
Anxiety
bearing process
Fear
Urinary retention
Gastric cancer
Glaucoma
Acute pain
Anxiety
Gastric ulcer Deficient knowledge (specify)
Acute pain Disturbed sensory perception
Anxiety (visual)
Imbalanced nutrition: less Grieving
than body requirements Risk for falls
Ineffective tissue perfusion (GI) Risk for injury
Glomerulonephritis
Risk for shock
Stress overload
Excess fluid volume
Gastroenteritis Imbalanced nutrition: less
Deficient fluid volume than body requirements
Diarrhea Ineffective tissue perfusion
Risk for deficient fluid volume (renal)
Risk for imbalanced body Risk for infection
temperature
Gonorrhea
Genital herpes Deficient knowledge (specify)
Deficient knowledge (specify) Ineffective community coping
Ineffective community coping Ineffective sexuality patterns
Moral distress Disturbed sensory perception

Risk for infection Disturbed thought processes
Risk-prone health behavior Dressing or grooming self-
Sexual dysfunction care deficit
Fear
Gout Imbalanced nutrition: less
Acute pain
Deficient knowledge
(specify) Impaired gas exchange
Impaired memory
Impaired parenting
than body requirements Impaired physical mobility
Impaired social interaction
GuillainBarr syndrome Impaired swallowing
Activity intolerance Impaired verbal communica-
Acute pain tion
Anxiety Ineffective thermoregulation
Bathing or hygiene self-care Ineffective tissue perfusion
deficit Posttrauma syndrome
Bowel incontinence Powerlessness
Fatigue Risk for activity intolerance
Impaired gas exchange Risk for aspiration
Impaired physical mobility Risk for constipation
Impaired spontaneous venti- Risk for delayed develop-
lation ment
Ineffective airway clearance Risk for disuse syndrome
Ineffective breathing pattern Risk for imbalanced body
Ineffective coping temperature
Risk for urge urinary inconti- Risk for imbalanced fluid
nence volume
Headaches Risk for injury
Acute pain Risk for trauma
Ineffective coping Risk for urge urinary inconti-
Insomnia nence
Head injury Sleep deprivation
Activity intolerance Total urinary incontinence
Acute confusion Unilateral neglect
Bowel incontinence Head or neck cancer
Chronic confusion Acute pain
Chronic sorrow Anxiety
Decreased intracranial adap- Disturbed body image
tive capacity Disturbed sensory perception
Deficient knowledge (specify) (gustatory)
Delayed growth and develop- Impaired oral mucous mem-
ment brane
Disturbed body image Impaired tissue integrity
437
Impaired verbal communica- Risk for imbalanced body
tion temperature
Ineffective airway clearance Risk for injury
Risk for shock
Heart failure Risk for trauma
Acute pain
Caregiver role strain Hemorrhage
Death anxiety Deficient fluid volume
Decreased cardiac output Impaired oral mucous mem-
Deficient knowledge (specify) brane
Excess fluid volume Ineffective thermoregulation
Fatigue Ineffective tissue perfusion
Hopelessness (renal)
Imbalance nutrition: more Risk for aspiration
Hemorrhoids
Acute pain
Constipation
Ineffective tissue perfusion Hemothorax
Powerlessness Acute pain
Risk for activity intolerance Anxiety
Risk for caregiver role strain Deficient fluid volume
Risk for imbalanced fluid vol- Fear
ume Impaired gas exchange
Risk for injury Impaired spontaneous venti-
lation
Hemodialysis
Deficient knowledge (specify) Hepatic coma
Disturbed body image Acute confusion
Disturbed thought processes Deficient fluid volume
Excess fluid volume Disturbed sensory perception
Interrupted family processes Disturbed thought processes
Readiness for enhanced hope Imbalanced nutrition: less
Risk for falls than body requirements
Risk for infection Impaired skin integrity
Spiritual distress Moral distress
Risk for acute confusion
Hemophilia
Risk for infection
Acute pain
Risk for injury
Impaired gas exchange Hepatitis
Ineffective protection Deficient knowledge (specify)
Parental role conflict Ineffective community coping
Readiness for enhanced cop- Nausea
ing family Readiness for enhanced com-
Risk for falls munity coping
Hip fracture Compromised family coping

Compromised family coping Delayed growth and develop-
Deficient knowledge (specify) ment
Ineffective denial Disturbed body image
Ineffective sexuality patterns Imbalanced nutrition: less
Powerlessness than body requirements
Risk for activity intolerance Interrupted family processes
Risk for falls Risk for impaired skin
Risk for impaired skin integrity
integrity Risk for infection
Risk for injury
Spiritual distress
Hyperbilirubinemia
Interrupted breast-feeding
Hodgkins disease Risk for injury
Grieving
Imbalanced nutrition: less Hyperemesis gravidarum
than body requirements Deficient fluid volume
Impaired physical mobility Imbalanced nutrition: less
Impaired skin integrity than body requirements
Impaired tissue integrity Hyperosmolar hyperglycemic
Ineffective breathing pattern nonketotic syndrome
Ineffective protection Deficient fluid volume
Risk for complicated grieving Disturbed thought processes
Risk for infection Impaired skin integrity
Huntingtons disease Ineffective tissue perfusion
Bathing or hygiene self-care Risk for infection
deficit Risk for unstable glucose
Bowel incontinence level
Caregiver role strain Hyperparathyroidism
Compromised family coping Acute pain
Deficient knowledge (specify) Anxiety
Hopelessness Hopelessness
Impaired physical mobility Imbalanced nutrition: less
Impaired verbal communica- than body requirements
tion Ineffective breathing pattern
Ineffective health maintenance Ineffective coping
Risk for loneliness Risk for imbalanced body
Moral distress temperature
Risk for injury Risk for impaired skin
Social isolation integrity
Hydatidiform mole
Hyperpituitarism
Acute pain
Acute pain
Ineffective coping
Grieving
Hydrocephalus dignity
Acute pain Sexual dysfunction
Anxiety
439
Hypertension Imbalanced nutrition: less
Decreased cardiac output than body requirements
Deficient knowledge Ineffective coping
(specify) Ineffective thermoregulation
Excess fluid volume Risk for trauma
Hypopituitarism
Risk for disproportionate
interpretation syndrome growth
Ineffective denial Hypothermia
Ineffective sexuality patterns Deficient knowledge (specify)
Ineffective therapeutic regi- Hypothermia
men management Ineffective thermoregulation
Noncompliance (specify)
Powerlessness Hypothyroidism
Readiness for enhanced Activity intolerance
knowledge Compromised family coping
Readiness for enhanced uri- Constipation
nary elimination Decreased cardiac output
Risk-prone health behavior Disturbed body image
Situational low self-esteem Disturbed thought processes
Hyperthermia nence
Deficient knowledge (specify) Ineffective coping
Hyperthermia Ineffective sexuality patterns
Impaired oral mucous mem- Ineffective thermoregulation
brane Risk for delayed development
Ineffective thermoregulation Risk for disproportionate
Hyperthyroidism growth
temperature
Disturbed body image Ileostomy
Disturbed thought processes Anxiety
Ineffective thermoregulation Deficient fluid volume
Risk for imbalanced body Disturbed body image
temperature Fear
Sleep deprivation Imbalanced nutrition: less
Hypochondriasis than body requirements
Ineffective coping
Ineffective health mainte-
nance (GI)
Risk for infection
Hypoparathyroidism Situational low self-esteem
Anxiety
Impotence
Risk for compromised human Intoxication

dignity Disturbed sensory perception
Sexual dysfunction Disturbed thought processes
Situational low self-esteem Hypothermia
Urinary retention Impaired verbal communica-
tion
Incest Ineffective community thera-
Ineffective coping
Moral distress
Moral distress
Risk for aspiration
Posttrauma syndrome
Rape-trauma syndrome: com- Joint replacement
pound reaction Acute pain
Rape-trauma syndrome: Compromised family coping
silent reaction Deficient knowledge (specify)
Infertility (kinesthetic)
Complicated grieving Impaired physical mobility
Deficient knowledge (specify) Ineffective tissue perfusion
Ineffective coping Risk for contamination
Situational low self-esteem Risk for infection
Stress overload Risk for injury
Inhalation injuries Juvenile rheumatoid arthritis
Ineffective thermoregulation Compromised family coping
Risk for injury Defensive coping
Risk for suffocation Disturbed sensory perception
Interstitial pulmonary (tactile)
fibrosis Grieving
Activity intolerance Impaired physical mobility
Deficient knowledge (specify) Ineffective health mainte-
Grieving nance
Impaired gas exchange Risk for unstable glucose
Ineffective breathing pattern level
Ineffective coping Kidney transplantation
Spiritual distress Deficient fluid volume
Intestinal obstruction Deficient knowledge (specify)
Acute pain Delayed surgical recovery
Constipation Disturbed body image
Imbalanced nutrition: less Ineffective protection
than body requirements Interrupted family processes
Ineffective tissue perfusion Risk for infection
(GI) Labor and delivery
Risk for aspiration Acute pain
Risk for deficient fluid vol- Anxiety
ume Deficient knowledge (specify)
Risk for imbalanced fluid vol- Effective breast-feeding
ume Impaired skin integrity
Urinary retention
441
Ineffective coping Ineffective airway clearance
Risk for injury Ineffective breathing pattern
Total urinary incontinence Ineffective coping
Urinary retention Ineffective tissue perfusion
(cardiopulmonary)
Laryngeal cancer
Grieving
temperature
Leukemia
Acute pain Lung cancer
Grieving Activity intolerance
Hopelessness Death anxiety
Imbalanced nutrition: less Fear
than body requirements Hopelessness
Impaired gas exchange Imbalanced nutrition: less
Impaired oral mucous mem- than body requirements
brane Impaired gas exchange
Impaired tissue integrity Impaired tissue integrity
Ineffective protection Impaired verbal communica-
Ineffective tissue perfusion tion
(cardiopulmonary) Ineffective airway clearance
Ineffective tissue perfusion Ineffective breathing pattern
(renal) Powerlessness
Risk for falls Lupus erythematosus
Risk for imbalanced body Decreased cardiac output
temperature Imbalanced nutrition: less
Risk for infection than body requirements
Risk for injury Impaired physical mobility
Liver transplantation Ineffective tissue perfusion
Anxiety Risk for infection
Compromised family coping Risk-prone health behavior
Deficient knowledge (specify) Lyme disease
Delayed surgical recovery Activity intolerance
Fear Acute pain
Ineffective coping Fatigue
Ineffective protection Hyperthermia
Ineffective tissue perfusion Impaired skin integrity
(cardiopulmonary)
Ineffective tissue perfusion (GI) Lymphomas
Ineffective tissue perfusion Death anxiety
(renal) Grieving
Moral distress Hopelessness
Risk for impaired liver func- Impaired tissue integrity
tion Ineffective protection
Risk for infection Risk for infection
Lung abscess Macular degeneration

Acute pain Activity intolerance
Anxiety Disturbed sensory perception
Impaired gas exchange (visual)
Ineffective denial Excess fluid volume

Powerlessness Fear
Readiness for enhanced hope Hyperthermia
Risk for caregiver role strain Ineffective airway clearance
Risk for falls Ineffective breathing pattern
Risk for imbalanced fluid vol-
Malnutrition ume
Risk for infection
Ineffective community coping Menopause
Risk for injury Ineffective sexuality patterns
Insomnia
Maternal psychological stress Sexual dysfunction
Anxiety Situational low self-esteem
Ineffective breast-feeding Stress overload
Interrupted breast-feeding
Powerlessness Metabolic acidosis
Meconium aspiration Disturbed thought processes
syndrome Impaired oral mucous mem-
Ineffective breathing pattern brane
Risk for injury Ineffective breathing pattern
Melanoma Risk for injury
Decisional conflict Metabolic alkalosis
Defensive coping Deficient fluid volume
Disturbed body image Disturbed thought processes
Fatigue Impaired oral mucous mem-
Hopelessness brane
Impaired oral mucous mem- Ineffective breathing pattern
brane Risk for injury
Powerlessness
Spiritual distress Mitral insufficiency
Mnires disease Decreased cardiac output
Disturbed sensory perception Deficient knowledge (specify)
(auditory) Fatigue
Impaired physical mobility Ineffective tissue perfusion
Insomnia (cardiopulmonary)
Nausea
Risk for falls Mitral stenosis
Risk for trauma Activity intolerance
Meningitis Deficient knowledge (specify)
Acute pain Fatigue
Bowel incontinence Ineffective tissue perfusion
Deficient fluid volume (cardiopulmonary)
(auditory) Mood disorders
Impaired religiosity
Ineffective community thera-
(visual)
443
Powerlessness Readiness for enhanced family
Risk for suicide coping
Self-mutilation Risk for activity intolerance
Social isolation Risk for caregiver role strain
Spiritual distress Risk for infection
Multiple births Risk for urge urinary inconti-
Anxiety
nence
Impaired parenting
Ineffective coping
Risk for injury Multisystem trauma
Stress urinary incontinence Anxiety
Multiple myeloma deficit
Acute pain
Dysfunctional ventilatory
Excess fluid volume
weaning response
Fatigue
Grieving
Powerlessness
Risk for infection
than body requirements Risk for suffocation
Risk for trauma
(cerebral)
Risk for infection Muscular dystrophy
Multiple sclerosis Deficient knowledge (specify)
Acute pain
Bowel incontinence
(kinesthetic)
Hopelessness
Death anxiety
nance
Low self-esteem
care deficit Readiness for enhanced family
Fatigue
coping
Grieving
than body requirements nence
Impaired memory
Impaired spontaneous venti- Myasthenia gravis
lation Bowel incontinence
Impaired urinary elimination Chronic low self-esteem
Ineffective airway clearance Dressing or grooming self-
Ineffective health maintenance care deficit
Ineffective sexuality patterns Dysfunctional ventilatory
Ineffective therapeutic regi- weaning response
men management Fatigue
Fear Neurologic impairment

Impaired gas exchange (neonatal)
Impaired physical mobility Compromised family coping
Impaired verbal communica- Ineffective infant feeding
tion pattern
Neuromuscular trauma
care
Overflow urinary inconti-
nence
nence
Posttrauma syndrome
Myocardial infarction Risk for aspiration
Activity intolerance Risk for constipation
Acute pain Risk for disuse syndrome
Anxiety Total urinary incontinence
Compromised family Unilateral neglect
coping
Nutritional deficiencies
Death anxiety
Ineffective coping
Ineffective denial
Risk for infection
Ineffective tissue perfusion Obesity
Readiness for enhanced spiri- Imbalance nutrition: more
tual well-being than body requirements
Risk for spiritual distress Readiness for enhanced nutri-
Risk-prone health behavior tion
Sedentary lifestyle Readiness for enhanced self-
Sexual dysfunction concept
Situational low self-esteem Risk for constipation
Sleep deprivation Risk for impaired skin
Spiritual distress integrity
Narcissistic personality disorder Stress urinary incontinence
Fear
Ineffective coping Obsessivecompulsive
disorder
Neonatal asphyxia Anxiety
Decisional conflict
Disturbed personal identity
ment Impaired home maintenance
Hypothermia
Ineffective coping
Ineffective denial
Risk for aspiration
Insomnia
Risk for injury
Risk for impaired religiosity
Neonatal hyperbilirubinemia Risk for injury
Interrupted breast-feeding Risk for suicide
445
Self-mutilation Ovarian cancer
Sleep deprivation Constipation
Social isolation Death anxiety
Fear
Organic brain syndrome Grieving
Adult failure to thrive
ume Impaired tissue integrity
Osteoarthritis Nausea
Activity intolerance Powerlessness
Acute pain Readiness for enhanced hope
Compromised family coping Risk for falls
Deficient knowledge (specify) Spiritual distress
Disturbed body image Urinary retention
Panic disorder
care deficit Anxiety
than body requirements Fear
Ineffective coping
Insomnia
Powerlessness
Risk for falls
Risk for posttrauma syn-
Risk for injury
drome
Sleep deprivation
Osteomyelitis Paralysis
Acute pain
Bowel incontinence
Ineffective coping
Hopelessness
(specify) Impaired skin integrity
Risk for infection
Ineffective coping
Risk for injury
Osteoporosis nance
Deficient knowledge (specify) Ineffective role performance
Disturbed body image Ineffective sexuality patterns
Fear Powerlessness
Ineffective denial Reflex urinary incontinence
Ineffective sexuality patterns Risk for caregiver role strain
Loneliness Risk for impaired skin
Powerlessness integrity
Risk for falls
Parkinsons disease
Risk for injury
Risk for trauma
Bowel incontinence
Social isolation
Compromised family coping Decreased cardiac output

Death anxiety Ineffective tissue perfusion
Deficient knowledge (specify) (cardiopulmonary)
Perinatal trauma
(tactile)
ment
Hypothermia
Grieving
Risk for injury
Hopelessness
Imbalanced nutrition: less Peripheral vascular disease
than body requirements Activity intolerance
Impaired home maintenance Acute pain
Impaired physical mobility Deficient diversional activity
Ineffective breathing pattern Deficient knowledge (specify)
Ineffective coping Impaired physical mobility
Ineffective health mainte- Impaired skin integrity
nance Impaired tissue integrity
Ineffective role performance Risk for falls
Ineffective sexuality patterns Risk for impaired skin
Ineffective therapeutic regi- integrity
men management Risk for infection
Powerlessness Risk for injury
Readiness for enhanced ther- Risk for peripheral neurovas-
apeutic regimen management cular dysfunction
Risk for aspiration
Risk for caregiver role strain Peritoneal dialysis
Risk for compromised human Defensive coping
dignity Deficient fluid volume
Risk for injury Deficient knowledge (specify)
Risk for loneliness Disturbed body image
Risk for urge urinary inconti- Excess fluid volume
nence Imbalanced nutrition: less
Social isolation than body requirements
Passiveaggressive Risk for infection
personality disorder
Anxiety Peritonitis
Disturbed personal identity Acute pain
Fear Anxiety
Ineffective coping Decreased cardiac output
Pelvic inflammatory disease Nausea
Acute pain Risk for infection
Sexual dysfunction Personality disorders
Decisional conflict
Pericarditis Interrupted family processes
Activity intolerance Risk for loneliness
Acute pain Risk for self-directed violence
Anxiety Risk for suicide
447
Sexual dysfunction Pneumothorax
Social isolation Anxiety
Phobic disorder Fear
Anxiety
Disturbed personal identity
Acute pain
Fear
Ineffective coping
(cardiopulmonary)
Powerlessness
Risk for loneliness
lation
Social isolation
Poisoning
Placenta previa Contamination
Anxiety
Fear
ment
Ineffective denial
Pleural effusion (olfactory)
Acute pain Disturbed sensory perception
Dysfunctional ventilatory (tactile)
weaning response Ineffective tissue perfusion
Hyperthermia (renal)
Ineffective breathing pattern Risk for aspiration
Risk for infection Risk for injury
Risk for poisoning
Pleurisy
Acute pain Polycystic kidney disease
Fatigue Acute pain
Impaired gas exchange Defensive coping
Ineffective breathing pattern Deficient knowledge
(specify)
Pneumonia Ineffective tissue perfusion
Bathing or hygiene self-care (renal)
deficit Interrupted family processes
Deficient fluid volume Moral distress
Imbalanced nutrition: less Risk for infection
Impaired gas exchange Polycythemia vera
Impaired physical mobility Acute pain
Impaired spontaneous venti- Disturbed sensory perception
lation (visual)
Impaired verbal communica- Impaired gas exchange
tion Impaired skin integrity
Postpartum hemorrhage
Anxiety
(cardiopulmonary) Ineffective tissue perfusion
(cardiopulmonary)
sleep Ineffective tissue perfusion
Risk for aspiration
(cerebral)
Risk for infection
Posttraumatic stress disorder Ineffective breathing pattern

Disturbed sensory perception Ineffective infant feeding pat-
Disturbed thought processes tern
Hopelessness Ineffective thermoregulation
Posttrauma syndrome Interrupted breast-feeding
Powerlessness Readiness for enhanced par-
Risk for loneliness enting
Risk for posttrauma syn- Risk for aspiration
drome Risk for delayed development
Situational low self-esteem Risk for disorganized infant
behavior
Pregnancy
Risk for impaired parent
Anxiety
infantchild attachment
Impaired individual resiliance
syndrome
Ineffective coping Pressure ulcers
Ineffective tissue perfusion Imbalanced nutrition: less
(peripheral) than body requirements
Interrupted family processes Impaired physical mobility
Readiness for enhanced fluid Impaired skin integrity
balance Impaired tissue integrity
Risk for constipation Ineffective protection
Risk for deficient fluid volume
Premature labor Risk for infection
Anxiety
Deficient knowledge Prolapsed intervertebral disk
(specify) Acute pain
Effective breast-feeding Impaired physical mobility
Impaired parenting Reflex urinary incontinence
Ineffective coping Urinary retention
Risk for infection Prostate cancer
Situational low self-esteem Acute pain
Premature rupture of Chronic sorrow
membranes Impaired tissue integrity
Deficient fluid volume Sexual dysfunction
Risk for infection Urinary retention
Prematurity Prostatectomy
Compromised family coping Disturbed body image
Delayed growth and develop- Impaired skin integrity
ment Risk for infection
Disorganized infant behavior Urinary retention
Hypothermia Pseudomembranous colitis
Imbalanced nutrition: less Deficient fluid volume
than body requirements Diarrhea
Impaired verbal communica- Impaired skin integrity
tion Ineffective tissue perfusion
Ineffective breast-feeding (cardiopulmonary)
449
Ineffective tissue perfusion (GI) Risk for aspiration
Ineffective tissue perfusion Risk for imbalanced body
(renal) temperature
Psoriasis Radiation therapy
Disturbed body image Acute pain
Impaired skin integrity Deficient fluid volume
Powerlessness Diarrhea
Risk for imbalanced body Imbalanced nutrition: less
temperature than body requirements
Social isolation Impaired oral mucous mem-
brane
Pulmonary edema Impaired physical
mobility
deficit Nausea
Sexual dysfunction
Dysfunctional ventilatory
weaning response Rape
Excess fluid volume Anxiety
Fear Chronic sorrow
Impaired gas exchange Complicated grieving
Impaired verbal communica- Fear
tion Moral distress
Ineffective airway clearance Posttrauma syndrome
Ineffective breathing pattern Rape-trauma syndrome
Ineffective tissue perfusion Risk for compromised human
(cardiopulmonary) dignity
Pulmonary embolus Social isolation
Acute pain
Anxiety Raynauds disease
Activity intolerance Deficient knowledge
Decreased cardiac output (specify)
Deficient fluid volume Disturbed sensory perception
Impaired gas exchange (tactile)
Impaired verbal communica- Impaired tissue integrity
tion Ineffective tissue perfusion
Ineffective breathing pattern (peripheral)
Risk for decreased cardiac Risk for impaired skin
tissue perfusion integrity
Pyelonephritis Renal calculi
Acute pain Acute pain
Excess fluid volume Ineffective denial
Impaired physical mobility Risk for infection
Risk for infection Urinary retention
Pyloric stenosis Renal cancer

Imbalanced nutrition: less Acute pain
than body requirements Deficient fluid volume
Renal disease: End-stage Disturbed body image

Caregiver role strain Dressing or grooming self-
Chronic low self-esteem care deficit
Decisional conflict Impaired physical mobility
Defensive coping Ineffective coping
Excess fluid volume Ineffective denial
Grieving Ineffective health mainte-
Hopelessness nance
Ineffective coping Ineffective protection
Ineffective denial Insomnia
Ineffective role performance Risk for disuse syndrome
Ineffective sexuality patterns Risk for falls
Risk for caregiver role strain Risk for injury
Risk for disuse syndrome Sexual dysfunction
Risk for infection
Risk for poisoning
Salmonella
Constipation
Diarrhea
Spiritual distress
Hyperthermia
Respiratory distress syndrome Nausea
Impaired gas exchange Risk for deficient fluid vol-
Ineffective airway clearance ume
Ineffective breathing pattern Risk for infection
Ineffective thermoregulation Urinary retention
Risk for infection
Sarcoidosis
Reyes syndrome Activity intolerance
Decreased intracranial adap- Acute pain
tive capacity Decreased cardiac output
Delayed growth and develop- Disturbed body image
ment Impaired gas exchange
Impaired physical mobility Ineffective breathing pattern
Schizophrenia
Rheumatic fever Anxiety
Acute pain Bathing or hygiene self-care
Anxiety deficit
Decreased cardiac output Caregiver role strain
Deficient knowledge (specify) Disturbed sensory perception
Fatigue Disturbed thought processes
Hyperthermia Functional urinary inconti-
Impaired gas exchange nence
Impaired physical mobility Hopelessness
Ineffective breathing pattern Impaired home maintenance
Risk for infection Impaired social interaction
Ineffective coping
Rheumatoid arthritis
Acute pain
Insomnia
451
Risk for caregiver role strain Risk for other directed
Risk for injury violence
Risk for poisoning Risk for self-directed
Risk for self-directed violence violence
Risk for suicide
Shaken baby syndrome
Sexual dysfunction
Impaired parenting
Social isolation
Seizure disorders Risk for impaired parenting
Anxiety
Chronic low self-esteem Shock
Delayed growth and develop- Decreased cardiac output
ment Deficient fluid volume
Disturbed sensory perception Impaired gas exchange
(tactile) Impaired oral mucous mem-
Impaired environmental brane
interpretation syndrome Impaired spontaneous venti-
Impaired memory lation
Ineffective airway clearance Ineffective airway clearance
Ineffective breathing pattern Ineffective tissue perfusion
Ineffective coping (cardiopulmonary)
Risk for delayed development Ineffective tissue perfusion
Risk for spiritual distress (cerebral)
Risk for trauma Ineffective tissue perfusion
Social isolation (renal)
Risk for infection
Self-destructive behavior
Anxiety Sickle cell anemia
Chronic low self-esteem Acute pain
Ineffective denial Impaired gas exchange
Risk for poisoning Impaired physical mobility
Risk for self-directed violence Ineffective protection
Risk for self-mutilation Ineffective tissue perfusion
(peripheral)
Sepsis Ineffective tissue perfusion
Acute confusion (renal)
Acute pain
Diarrhea Sjgrens syndrome
Dysfunctional ventilatory Acute pain
weaning response Disturbed sensory perception
Hyperthermia (gustatory)
Hypothermia Impaired oral mucous mem-
Imbalanced nutrition: less brane
than body requirements Somatic disorder
lation
Ineffective thermoregulation Spina bifida
Latex allergy response
Sexual assault
Risk for latex allergy
Posttrauma syndrome
response
Rape-trauma syndrome
Spinal cord defects Risk for autonomic

Chronic low self-esteem dysreflexia
Delayed growth and develop- Risk for constipation
ment Risk for delayed development
Impaired urinary elimination Risk for disuse syndrome
Overflow urinary inconti- Risk for impaired skin integrity
nence Risk for infection
Readiness for enhanced cop- Risk for trauma
ing family Risk for urge urinary inconti-
Risk-prone health behavior nence
Total urinary incontinence Risk-prone health behavior
Sleep deprivation
Spinal cord injury
Social isolation
Autonomic dysreflexia
Urinary retention
deficit Spinal tumor
Bowel incontinence Autonomic dysreflexia
Chronic pain Bowel incontinence
Chronic sorrow Chronic low self-esteem
Complicated grieving Disturbed sensory perception
Constipation (kinesthetic)
Deficient diversional activity Dressing or grooming self-
Deficient knowledge (specify) care deficit
Delayed growth and develop- Impaired physical mobility
ment Impaired urinary elimination
Disturbed body image Ineffective breathing pattern
Disturbed sensory perception Reflex urinary incontinence
Fear Risk for autonomic dysre-
Hopelessness flexia
Impaired physical mobility Risk for impaired skin
Impaired spontaneous venti- integrity
lation Risk for injury
Impaired transfer ability Risk for urge urinary inconti-
Impaired urinary elimination nence
Ineffective airway clearance Sexual dysfunction
Ineffective health mainte- Situational low self-esteem
nance Total urinary incontinence
Ineffective therapeutic regi-
Spouse abuse
Anxiety
men management
Defensive coping
Moral distress
Posttrauma syndrome
Fear
Powerlessness
Posttrauma syndrome
Readiness for enhanced com-
Rape-trauma syndrome
munication
Risk for other-directed vio-
Readiness for enhanced ther-
apeutic regimen management lence
Stress overload
Reflex urinary incontinence
453
Streptococcal throat Ineffective thermoregulation
Acute pain Ineffective tissue perfusion
Hyperthermia (cerebral)
Impaired oral mucous mem- Interrupted family processes
brane Powerlessness
Risk for infection Readiness for enhanced family
processes
Stroke
Risk for activity intolerance
Acute confusion
Risk for aspiration
deficit
Bowel incontinence
dignity
Risk for disuse syndrome
Chronic confusion
Risk for impaired skin
Chronic sorrow
integrity
Risk for injury
Constipation
Risk for poisoning
Death anxiety
Decreased intracranial adap-
Sleep deprivation
tive capacity
Social isolation
Unilateral neglect
(tactile)
Fatigue Suicidal behavior
Functional urinary inconti- Anxiety
nence Chronic low self-esteem
Hopelessness Ineffective denial
Imbalance nutrition: more Readiness for enhanced spiri-
than body requirements tual well-being
Imbalanced nutrition: less Risk for poisoning
than body requirements Risk for self-directed violence
Impaired environmental Risk for self-mutilation
Syphilis
Ineffective community coping
Impaired memory
Risk for infection
Impaired social interaction
Risk for injury
Impaired swallowing
Impaired urinary elimination Tendinitis
Impaired verbal communica- Activity intolerance
tion Impaired physical mobility
Impaired walking Ineffective role performance
Testicular cancer
Acute pain
nance Fear
Sexual dysfunction
Thoracic surgery Trigeminal neuralgia

Acute pain Acute pain
Deficient fluid volume Anxiety
Fatigue Deficient knowledge (specify)
Fear Imbalanced nutrition: less
Impaired gas exchange than body requirements
Tuberculosis
Fatigue
Risk for infection
Fear
Thrombophlebitis Imbalanced nutrition: less
Acute pain than body requirements
Impaired gas exchange Impaired dentition
Impaired skin integrity Impaired gas exchange
Ineffective tissue perfusion Ineffective airway clearance
(peripheral) Ineffective breathing
Risk for impaired skin pattern
integrity Risk for infection
Risk for infection Risk for loneliness
Tracheoesophageal fistula Social isolation
Imbalanced nutrition: less Urinary calculi
than body requirements Acute pain
Risk for aspiration Anxiety
Tracheostomy Impaired urinary elimination
Imbalanced nutrition: less Ineffective tissue perfusion
than body requirements (renal)
Impaired comfort Readiness for enhanced uri-
Impaired skin integrity nary elimination
Impaired verbal communica- Risk for infection
tion Urinary diversion
Risk for infection Acute pain
Transient ischemic attacks Constipation
Acute confusion Disturbed personal identity
Disturbed sensory perception Grieving
(tactile) Impaired skin integrity
Impaired environmental Ineffective breathing
interpretation syndrome pattern
Impaired memory Ineffective sexuality
Ineffective tissue perfusion patterns
(cerebral) Infection
Sexual dysfunction
Trauma
Death anxiety Urinary incontinence
Disabled family coping Anxiety
Disturbed sensory perception Functional urinary inconti-
(auditory) nence
Energy field disturbance Impaired skin integrity
Risk for self-directed violence Overflow urinary incontinence
455
Reflex urinary incontinence Ineffective tissue perfusion
Social isolation (cardiopulmonary)
Stress urinary incontinence Ineffective tissue perfusion
Total urinary incontinence (cerebral)
Urinary tract infection (peripheral)
Acute pain
Risk for shock
Readiness for enhanced Vascular insufficiency
urinary elimination Impaired tissue integrity
Risk for infection Risk for peripheral neurovas-
Risk for urge urinary inconti- cular dysfunction
nence
Viral hepatitis
Acute pain
Uterine prolapse Imbalanced nutrition: less
Disturbed body image than body requirements
Stress urinary incontinence Impaired skin integrity
Risk for impaired skin integrity
Uterine rupture Risk for infection
Acute pain
Social isolation
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APPENDICES
457
Appendix A: Assessment Parameters Based on

Taxonomy of Nursing Practice*
CLASS OBJECTIVE DATA
Functional Domain
Activity/exercise Functional mobility status:

0 completely independent
1 requires use of equipment or device
3 requires help from another person and equipment
or device
4 dependent, doesnt participate in activity
Comfort Muscle tone: listless to rigid
Autonomic responses: pulse rate, diaphoresis, blood pressure,
respiratory rate. Behavior changes: loss of consciousness
(LOC), increased irritability, lethargy, or aggression; elderly
and young children can manifest pain in behavior changes.
Growth and development Height/weightcompare to pediatric growth grid: Concern
if child has 2 SD on the Centers for Disease Control
and Prevention Growth Chart Bone/Tooth development
Developmental Examination (DDS II)
Nutrition Weight (compare to normal chart)
Laboratory studies: serum albumin, glucose: infant 60105
Children and adults 70115.
Bilirubin total: normal adults 0.11.2 mg/dl
0- to 1-day old: 6 mg/dl
1- to 2-day old: 12 mg/dl
3- to 5-day old 12 mg/dl
Breast examination: sore or bleeding nipples, engorgement,
signs of infection, signs of oxytocin release
Self-care Self-care status: score separately for: bathing, hygiene,
dressing, grooming, feeding, and toileting
0 completely independent
1 requires use of equipment or device
3 requires help from another person and equipment or
device
4 dependent, doesnt participate in activity
Sexuality Use of antihypertensives, neuroleptics, sedatives,
tranquilizers, or sexual enhancing drugs
Sleep/rest
From Unifying Nursing Languages: The Harmonization of NANDA, NIC, and NOC, by J. M. Dochterman
and D. A. Jones (Eds.), 2003, Washington, DC: NursesBooks.org.
458
SUBJECTIVE DATA
Usual activity level, daily schedule, usual exercise patterns

Reports of inability to carry out activities of daily living (ADLs) or instrumental activities of daily
living; overwhelming lack of energy (thyroid studies: abnormalities in thyroid hormone levels
can manifest in decreased energy levels)
Characteristics of pain: location, duration, time of day when pain is most severe, sources of
relief
Placement on Pain Scale 110 with 10 being most severe; for children: faces scale
Use of pain medications (including prescription/and over-the-counter/illegal)
Growth history; genetic factors, lead screening,

Sexual Maturation index Scale for Adolescents;
Signs of puberty for girl as early as 8 and boy 9; concern if no signs of puberty in girls 13 and
boys 14
Daily food intake, usual dietary patterns, food preferences, food allergies, changes in weight,
dentures (proper fit). Report of difficulty breast-feeding or incomplete emptying (normal
weight gain key in assessing nutritional status for infants and children). Infants should reach
birth weight by 2 weeks, double birth weight by 6 months, triple birth weight by 1 year and
4 birth weight by 2.5; slow weights gain 23 lb a year normal until adolescence.
Body mass index: concern if greater than 18 kg/m2
Report of difficulty or inability to carry out some one or more ADLs
Perception of sexual identity; sexuality status: changes in sexual behavior, usual patterns of
sexuality, sexual dysfunction, impotence, vaginismus, decreased or increased libido,
dysparuenia, premature ejaculation
Description of sleep patterns, usual sleep routines, expression of tiredness or lack of being
rested after sleep, use of sleep-disturbing drugs, usual activity and work patterns, sleep
environment
Pain: medications, alcohol consumption, depression, caffeine intake, and stress affect
sleep
Sleep apnea: enlarged tonsils in young children; in older children and adults obesity may be a
finding for sleep apnea
(Continued)
459

Taxonomy of Nursing Practice*(continued)
Values/beliefs
Physiological Domain
Cardiac function Cardiovascular status: heart rate and rhythm; skin color,
temperature, and turgor; jugular vein distension,
hepatojugular reflux, heart sounds, blood pressure,
peripheral pulses, electrocardiogram, results of
echocardiogram
Elimination Gastrointestinal status: stool characteristics, bowel sounds,
abdominal distension
Genitourinary status: characteristics of urine, palpation of
bladder, results of Intravenous pyelogram, electrolytes,
blood urea nitrogen, creatinine level, urinalysis, intake
and output, mucous membranes, urine specific gravity
Fluid and electrolytes Fluid and electrolyte status, weight, intake and output,
urine specific gravity, skin turgor, mucous membranes,
results of laboratory studies (hemoglobin/hematocrit
overhydration or dehydration; Hematocrit dehydration
decreased if the person has been rehydrated too
rapidly or is retaining fluid. Hematocrit should be
3 times the hemoglobin. Serum electrolytes, blood urea
nitrogen, urinalysis, arterial blood gases [ABGs]),
characteristics of stool, vomiting, nasogastric drainage,
blood loss
Neurocognition Neurological status, level of consciousness, orientation to
person, place, and time, pupillary response, sensory
status, motor status. Mental status, abstract thinking,
insight, judgment, recent and remote memory; Mini-
Mental Status Examination
Physical regulation Vital signs (blood pressure, Temperature, Pulse, Respirations;

signs of inflammation or allergic responses; skin status,
color, temperature, and turgor. Tactile sensations in upper
and lower extremities, motor nerve function, peripheral
pulses (compare bilaterally using the following scale: 0
absent, 1 weak, barely palpable, 2 weak, diminished,
3 slightly weak, easily located, 4 normal, easily
located), vascular status (capillary refill time, blanching,
skin temperature, and skin color)
Reproduction
460
SUBJECTIVE DATA
Spiritual status, including religious affiliation, current perception of faith and religious practices,
spiritual beliefs linked to current distress, change in usual spiritual practices, relationship
between spiritual beliefs and everyday living, unmet spiritual needs (meaning and purpose,
love and relatedness, forgiveness)
History of valvular disorder, congenital heart disease or myopathy, myocardial infarction,

congestive heart failure, shortness of breath, frequent respiratory infections, red flag for
undiagnosed cardiac conditions in children.
Bowel: usual elimination patterns, change in bowel patterns, reports of constipation or diarrhea,
history of laxative suppositories or enema use, history of gastrointestinal disorder
Urinary: History of urinary tract disorder (renal calculi, infection, trauma, surgery), elderly and
infants may only have behavioral changes to indicate urinary tract infection; night time bed
wetting in an older or previously toilet trained child can indicate urinary tract infection, usual
voiding pattern, report of urine leakage or retention, use of incontinence aids, perception of
bladder fullness
History of renal, cardiac, gastrointestinal disorders, burns, diabetes mellitus, use of diuretics or
rehydration fluid instead of water for imbalances when indicated.
History of spinal cord trauma, head trauma, alcoholism delirium, stroke, transient ischemic
attacks; description of symptoms, headache, nasal congestion, blurred vision, chest pain,
diaphoresis and flushing above the level of the spinal cord injury
List all medications (prescribed, over-the-counter, and illicit drugs) and responses. Changes in
LOC, balance, and behavior can indicate drug toxicity.
History of allergic responses to food, drugs, or other irritants (especially latex). Facial and
extremity swelling, difficulty in breathing, rashes, may indicate reaction.
Elevated esonophils indicates allergic response; exposure to heat or cold. History of burns,
fractures or trauma, mechanical (cast, brace, etc.) or vascular obstruction
Maternal history. Number of pregnancies, live births, abortions or miscarriages. History of

contraceptive use, sterilization procedures, fertility problems
(Continued)
461

Respiratory function Respiratory status, rate and depth of respirations, symmetry

of chest expansion, use of accessory muscles, palpation
for fremitus, percussion of lung fields, auscultation for
breath sounds, ABG levels: When the PCO2 and HCO3
increase and decrease together, the imbalance is
metabolic. When the PCO2 and HCO3 move in opposite
directions, think respiratory: metabolic together
respiratory apart; pulse oximetry; results of chest x-ray
film, cough, characteristics of sputum; results of
pulmonary function studies and sputum cultures;
presence or absence of gag and swallow reflexes;
artificial airway, ventilator settings
Sensation/perception Auditory status, ear position, size and symmetry, tympanic
membrane (cerumen, color of canal, deformities,
intactness or tension, landmarks), results of audiometric
evaluation (Rinne, Weber, Schwabach hearing tests and
speech and noise tests), use of hearing aid
Gustatory: taste sensation, including change from baseline,
ability to differentiate sweet, salty, sour, and bitter tastes;
changes in weight or smell
Kinesthetic: motor coordination and muscular strength,
flaccidity or atrophy; perception of body part location
and changes in position
Olfactory: olfactory status, nosebleeds, foul taste in mouth,
sneezing, postnasal drip, dry or sore mouth or throat,
excessive tearing, facial pain, eye pain
Tactile: impaired tactile perception (tingling, pain,
numbness; response to sharp and dull stimuli, signs of
bruises, cuts, scrapes, or other injury)
Visual: visual status, corneal reflex, extraocular movements,
fields of gaze, inspection of lid and eyeball,
opthalmascopy, palpation of lid and eyeball, pupil size
and accommodation, tonometry, use of glasses, contact
lenses or intraocular implants, visual acuity (near and
distant), visual fields
Tissue Integrity Oral: oral status, gums, lips, tongue, mucous membranes,
signs of salivary dysfunction, teeth
Skin: integumentary status, color, elasticity, hygiene, lesions,
moisture, sensation, quantity and distribution of hair,
texture, turgor, pressure ulcer (place, stage, size,
characteristics), complete blood cell count,
hemoglobin/hematocrit, serum albumin, blood
coagulation studies, serum electrolytes, mobility status,
urinary or bowel incontinence
462
SUBJECTIVE DATA
History of respiratory disorder, use of respiratory medications (for asthma, bronchitis,

emphysema, interstitial lung disease, pneumonia); smoking history
Auditory: history of ear disorders, trauma, surgery; perception of auditory ability; use of
adaptive auditory aids (lip reading, gestures, signing). Delayed development of speech and
language may indicate hearing loss. Gentamycin and aspirin toxicity can lead to hearing loss.
Bacterial meningitis strong link to hearing loss.
Tip of the ears not matching the outer canthus of the eye equal low set ears can be indicative
of mental retardation and congenital syndromes. Skin tags and sinus on the auricle may be
linked to kidney structural defects.
Gustatory: history of vitamin or mineral deficiency, neurologic or oral disorders, chemotherapy,
or radiation therapy; medication history (antidepressants such as clomipramine,
antineoplastic agents, penicillamine, captopril, lithium, interferon alfa-2a, levamisole,
zidovudine)
Kinesthetic: history of cerebral palsy, multiple sclerosis, muscular dystrophy, spinal disorders;
use of safety devices
Olfactory: history of nasal disease or allergy, intranasal drug abuse, surgery or trauma; use of
phenothiazines, estrogen, metronidazole, antineplastics, prolonged use of nasal
decongestants or topical anesthetics. Frequent sinus infections and colds can alter sense of
smell. Altered sense of smell can also indicate central nervous system damage
Tactile: history of chemotherapy, alcohol use, medications such as clomipramine, ceftizoximie,
amiodarone hydrochloride, dishlorphenamide, guanadrel, anistreplase, interferon alfa-2b,
zidovudine
Visual: history of eye disorders, trauma, surgery. Strabismus normal up to 6 months of age.
Childrens vision is about 20/30 until 7 to 8 years of age. May develop near sightedness after
puberty due to physiological change in the lens shape.
Oral: dental health history, tooth development, frequency of dental visits, frequency of brushing
and flossing; history of malnutrition, anorexia, bulimia, infections, allergies, lead poisoning,
rubella, caries, extractions, bridges, braces, dentures.
Skin: history of skin problems, trauma, lesions (color, borders, elevation, and bleeding), surgery,
chronic metabolic or systemic disease, immunocompromised, renal or hepatic disease,
radiation or chemotherapy. Trauma that does not fit history may indicate abuse.
Bruises that are on soft tissue areas, in a pattern, may indicate abuse.
Anticoagulants and antiseizure medications may cause bruising
(Continued)
463

Psychosocial Domain
Behavior
Communication Speech patterns, judgment, thoughts, perception of reality,

memory, characteristics of speech (coherence of topics,
logic and relevance of responses, volume, voice tone and
modulation, presence of speech defects such as stuttering,
fast or slow speech, slurred speech, dysarthria, garbled
speech, echolalia, aphasia, dysphasia), orientation, mood,
affect, gender and age; use of communication aids
Coping Evidence of physical injuries, laboratory studies (pregnancy

test, tests for sexually transmitted diseases)
Emotional Symptoms of anxiety, depression (Depression Screening

tool.)
HEEDSS screening tool for adolescents
Knowledge Learning ability (affective, cognitive, and psychomotor

domains), developmental stage, demonstrated skills in
managing health problems, memory, mental status,
orientation
Roles/relationships Family genogram, caregivers age, sex, level of education,
occupation, general health, nationality, area of residence
Infants status: muscle tone, reflexes, lethargy, irritability,
seizures, tremors; Brazelton Neonatal Behavioral
Assessment Scale, Dubowitz Maturity Scale, Bayley Scales
of Infant Development
Self-perception Musculoskeletal status, contractures, subluxation, muscle

atrophy, pain, deformity
464
SUBJECTIVE DATA
Patients understanding of health problem and treatment plan, past history with healthcare
providers, participation in healthcare planning and decision making; recognition and
realization of potential growth, health, autonomy
Developmental history of communication patterns, knowledge of difference among passive, assertive,
and aggressive responses Infants through nonverbal cues. Direct communication at parent.
Toddlers: direct communication at parents initially, talk at eye level with the child use play and
simple speech
Preschoolers: egocentric cannot empathize, magical thinking interferes with communication.
Use play and initially direct communication at parents.
School-age: concrete thinkers, take speech literally. Direct the communication at them. Simple
language with few analogies.
Adolescents: communicate with them in private and with parent.
Want honesty. Expect both childlike and adult like behavior. Dont use adolescents language. May
resist authority figures.
Need to use appropriate interpreter, do not use untrained personnel or family members to
communicate.
Allow elderly people time to reminisce about past.
Speak slowly so as to allow for auditory processing.
Do not yell at a hearing-impaired patient.
Face patient when speaking.
Patients perception of health problem, coping mechanisms, problem-solving ability, decision-
making competencies, relationships, family system, self-worth, patterns of coping with loss,
experiences with relocation
Health status, support systems, expressed concerns about impending death, history of loss,
changes in appetite, sleep and eating patterns, alcohol consumption
Changes in work or school performance, activity level or libido, expression of emptiness,
loneliness, low self-esteem, overwhelmed
Health status, educational level, cultural status, requests for information; demonstrated
understanding of material
Family status, including roles of family members, effects of illness on patients family, familys
understanding of patients illness, ability to meet needs of patient, quality of relationships
Cultural status, including affiliation with racial, ethnic, or religious groups
Parental status, including level of education, knowledge of growth and development, stability of
relationship
Infants status, including sleep patterns, prematurity, developmental disorder
Parentchild interaction
Verbal and nonverbal responses to actual (burns, surgery-amputation, mastectomy,
laryngectomy), or perceived change in body structure and function
(Continued)
465

Environmental Domain
Healthcare system
Populations Community demographics, including age and sex
distribution, ethnic groups, racial groups, education and
income level
Prevalence of health problems, availability of healthcare
services
Other data: drug and alcohol abuse, automobile accidents,
homicides, suicides, domestic violence, burglaries,
teenage pregnancy, sexually transmitted diseases, low-
birth-weight infants, incidence of congenital
abnormalities
Risk management Toxicology results, LOC, mental status, presence of
dangerous products
466
SUBJECTIVE DATA
Patients experiences with the healthcare system
Health history: accidents, adolescents most at risk for injury.

2- to 5-year-olds most at risk for poisoning and drowning. allergies, exposure to pollutants,
falls, hyperthermia, hypothermia, poisoning, seizures, trauma, sensoryperceptual changes
Support systems, financial resources
*Ralph, S. (2009). Assessment Parameters Based on Taxonomy of Nursing Practice. Copyright by
Author, Hamilton, VA.
467
Appendix B: Taxonomy of Nursing Practice:

A Common Unified Structure for Nursing Language
Domains
I. Functional II. Physiological III. Psychosocial IV. Environmental
domain includes domain domain domain
diagnoses, includes diagnoses, includes diagnoses, includes diagnoses,
outcomes, and outcomes, and outcomes, and outcomes, and
interventions to interventions to interventions to interventions to
promote basic needs promote optimal promote optimal promote and protect
biophysical health mental and the environmental
emotional health health and safety of
and social individuals, systems,
functioning and communities
Classes includes diagnoses, class outcomes, and interventions that pertain to:
Activity/exercise: Cardiac function: Behavior: Healthcare system:

Physical activity, Cardiac mechanisms Actions that Social, political, and
including energy used to maintain promote, maintain, economic structures
conservation and tissue profusion or restore health and processes for
expenditure the delivery of
healthcare services
Comfort: A sense of Elimination: Communication: Populations:
emotional, physical, Process related to Receiving, Aggregates of
and spiritual well- secretion and interpreting, and individuals, or
being and relative excretion of body expressing spoken, communities having
freedom from distress wastes written, and characteristics in
nonverbal messages common
Growth and Fluid and Coping: Risk
development: electrolyte: Adjusting or management:
Physical, emotional, Regulation of adapting to stressful Avoidance or control
and social growth fluid/electrolytes and events of identifiable health
and development acidbase balance threats
milestones
Nutrition: Neurocognition: Emotional:
Processes related to Mechanisms related A mental state or
taking in, to the nervous feeling that may
assimilating, and system and influence
using nutrients neurocognitive perceptions of the
functioning, including world
memory, thinking,
and judgment
Self-care: Ability to Pharmacological Knowledge:
accomplish basic function: Effects Understanding skill
and instrumental (therapeutic and in applying
activities of daily adverse) of information to
living medications or drugs promote, maintain,
and other and restore health
pharmacologically
active products
468
Sexuality: Physical Roles/

Maintenance or regulation: relationships:
modification of Body temperature, Maintenance and/or
sexual identity and endocrine, and modification of
patterns immune system expected social
responses to behaviors and
regulate cellular emotional
processes connectedness with
others
Sleep/rest: Reproduction: Self-perception:
The quantity and Processes related to Awareness of one's
quality of sleep, rest, human procreation body and personal
and relaxation and birth identity
patterns
Values/beliefs: Respiratory
Ideas, goals, function:
perceptions, Ventilation adequate
spiritual, and other to maintain arterial
beliefs that influence blood gasses within
choices or decisions normal limits
Sensation/
perception: intake
and interpretation of
information through
the senses, including
seeing, hearing,
touching, tasting,
and smelling
Tissue integrity:
Skin and mucous
membrane
protection to
support secretion,
excretion, and
healing
This structure is in the public domain and can be freely used without permission; neither the
structure nor a modification can be copyrighted by any person, group, or organization; any use
of the structure should acknowledge the following source: Dochterman, J. M., & Jones, D. A.
(Eds.). (2003). Unifying nursing language: The Harmonization of NANDA, NIC, and NOC.
Washington, DC: NursingBooks.Org.
469
Appendix C: Action Intervention Types

TYPE DEFINITION EXAMPLES
Determine Finding out or establishing Assess, monitor, observe, evaluate
Perform Doing a task Hygiene, insert, position, change, feed
Inform Telling about something Describe, explain, teach
Attend Being concerned about Assist, relate
Manage Being in charge of or Organize, refer, obtain
bringing order
Adapted from International Classification for Nursing Practice by International Council of

Nurses, 2005, p. 130, Geneva, Switzerland. Examples are not exhaustive.
470
LWBK392-IND_471-488.qxd 17/11/2009 09:28 AM Page 471 Aptara
INDEX
A Adherence behavior, 74, 236,

Abnormal rupture of 240, 296, 314, 320
membranes, 418 healthy diet, 242
Abortion, 418 ADL. See Activities of daily
Abruptio placentae, 418 living
Abuse cessation, 408 Adrenal insufficiency, 419
Abuse protection, 272, 274 Adrenocortical insufficiency, 419
Abuse protection support, Adult education, 56
275 Affective disorders, 419
child, 22 Aggression self-control, 362,
Abuse recovery, 274, 318 408
Abusive behavior, 362 Airway clearance
self-restraint, 408 ineffective, 1011
Acceptance (health status), 18, management, 11, 21, 149,
172, 236, 354 365, 407
Acidbase management, 141, patency, 10
145, 149, 211, 279, 405, suction, 11, 149, 371, 405
407 Alcohol addiction and abuse,
Acidbase monitoring, 341 419420
Acoustic neuroma, 418 Alcoholism, 128129
Acquired immunodeficiency Allergy management, 13, 15
syndrome, 418 Allergy response (localized), 14
Active exercise, 5 Alzheimers disease, 420
Active listening, 19, 61, 67, 93, Ambulation, 5, 115, 126, 228,
137, 165, 169, 257, 263, 332, 368, 41
279, 283, 285, 287, 309, balance, 412
351, 357, 359, 361 body mechanics promotion, 7
Activities of daily living, 4, 5, wheelchair, 228, 230
17, 45, 62, 412 Amniotic fluid embolism, 420
Activity Amputation, 420
intolerance, 4 Amyotrophic lateral sclerosis,
planning, ineffective, 23 421
therapy, 5, 7, 9, 115, 135, Analgesic administration, 251
219, 333, 335, 353, Anaphylactic shock, 421
415 Anaphylaxis management, 13, 15
tolerance, 45, 6, 134, 388 Anemias, 421
risk for, 67 Anger control assistance, 17, 87,
Adaptive equipment, 9 113, 363, 409
Addiction, drug, 432433 Angina pectoris, 421
471
472 Index
Animal-assisted therapy, 9 Asthma, 422423

Anorexia nervosa, 421, 433 Atelectasis, 10, 11, 423
Antiarrhythmic drugs, 47 Attachment process, 197
Anticipatory guidance, 17, 19, Attachment promotion, 199,
117, 157, 167, 311, 339, 201, 213, 253
359 Attention-deficit/ hyperactivity
Anticoagulant therapy, 114 disorder, 423
Antipyretics, 34 Autism, 423
Antisocial personality disorder, Autonomic dysreflexia, 2425
421 risk for, 2627
Anxiety, 1617
affective, 16 B
behavioral, 16 Balance, 126, 230, 328, 332,
cognitive, 16 392
control, 136 Bathing, 379
disorder, 422 Bathing/hygiene self-care deficit,
level, 16, 18, 78, 102, 208, 298299
270, 318, 338, 348, 404 Behavior management, 3, 123,
parasympathetic, 16 215, 241, 245, 321, 363,
physiological, 16 367, 409
reduction, 3, 17, 75, 79, 103, self-harm, 411
113, 121, 123, 137, 149, Behavior modification, 3, 103,
225, 263, 275, 289, 291, 165, 215, 221, 241, 251,
337, 347, 351, 359, 395, 315, 363, 373
399, 407 social skills, 17
self-control, 263, 362, 406 Bed mobility, impaired,
sympathetic, 16 226227
Aortic aneurysm, 422 Bed rest care, 227, 369
Aortic stenosis, 422 Bedside laboratory testing, 155,
Appetite, 164, 232, 326, 370 211, 279
Area restriction, 317, 319 Bells palsy, 423
Art therapy, 9 Benign prostatic hypertrophy,
Arterial insufficiency, 422 423
Artificial airway management, Biofeedback, 209
405 Bioterrorism preparedness, 81
Asphyxia, 422 Bipolar disorder
Aspiration depressive phase, 423
precautions, 11, 21, 365, 371 manic phase, 423
prevention, 10, 20, 21, 206, Bladder cancer, 424
364, 370 Bleeding, 3031
risk for, 2021 Blindness, 424
Assertive behavior, 61 Body
Assertiveness training, 267, 313, alignment, 5, 17
363 image, 33, 111, 164, 234,
Assessment information, 33, 40, 263, 270, 306, 308, 334,
64 336, 338
Index 473
disturbed, 3233 C
enhancement, 235, 309, Calming technique, 3, 17, 85,
339 103, 209, 225, 363
mechanics performance, 234, Cancer, 425426
332 Capillary blood sample, 213
mechanics promotion, 5, 115, Cardiac arrhythmias, 426
227, 393 Cardiac care, 383
positioning (self-initiated), Cardiac disease (end-stage), 426
226, 234, 328, 332, Cardiac output, decreased,
392 4647
Bone marrow transplantation, Cardiac pump effectiveness, 390
424 Cardiac tissue perfusion,
Bone sarcomas, 424 decreased, 382383
Borderline personality disorder, Cardiogenic shock, 426
424 Caregiver, 7
Bottle feeding, 213 ability, 49
Bowel emotional health, 82, 86,
care, 37 256
continence, 108 lifestyle disruption, 294
elimination, 73, 74, 76, 150, performance (direct care), 282
152, 212 physical health, 256
fistula, 424 stressors, 50, 82
incontinence, 3637 support, 83, 87, 295, 359
management, 75, 77, 213 well-being, 96
resection, 424 Carpal tunnel syndrome, 426
training, 305 Case management, 369, 375
Brain Cataracts, 426
abscess, 424 Catheter, 25, 27
tumors, 424 Cellulitis, 426
Breast Cerebral aneurysm, 426
cancer, 425 Cerebral edema, 211, 426
engorgement, 425 Cerebral palsy, 426
Breast-feeding Cerebral perfusion promotion,
assistance, 201, 213 225, 385
effective, 3839 Cerebral tissue perfusion,
establishment (infant), 200, ineffective, 384385
212 Cervical cancer, 426
ineffective, 4041 Chemotherapy, 427
interrupted, 4243 Chest physiotherapy, 21
maintenance, 200 Chest trauma, 427
Breathing pattern, ineffective, Child abuse, 427
4445 Child coping enhancement, 22
Bronchiectasis, 425 Child development (middle
Bronchitis, chronic, 427 childhood), 162, 164
Bulimia nervosa, 425, 433 Childbearing process, 5253
Burns, 425 enhanced 5253
474 Index
Childbirth, 427 Community

Childbirth preparation, 117 competence, 90, 94
Chlamydia, 427 coping, 9495
Chloride imbalance, 427 enhanced, 9495
Cholecystitis, 427Cirrhosis, 428 ineffective, 9091
Chronic sorrow, 354355 disaster preparedness, 81
Circulation status, 206, 258, 384 disaster readiness, 80
Circulatory care health
arterial insufficiency, 381, development, 91, 95
387, 389 status, 78, 80, 90, 94, 180
exercise promotion, 389 mental health resources, 17
mechanical assist device, 207 risk control, 94, 180
Circulatory precautions, 207, Complex relationship building,
259, 345, 381 315
Cleft lip or palate, 428 Compliance behavior, 236, 314,
Client satisfaction, 110, 112, 406 320, 372, 374
functional assistance, 296 Concentration, 2, 122, 214,
Cognition, 2, 126, 214, 224, 224, 346
226, 370 Conduct disorder, 429
Cognition orientation, 2 Conflict mediation, 113
Cognitive abilities, 61, 68 Confusion, 71
Cognitive orientation, 122, 224, acute, 6667
324, 326, 330 risk for, 7071
Cognitive restructuring, 137, chronic, 6869
269, 363 Congenital anomalies, 429
Cognitive stimulation, 115, 323, Congenital heart disease, 429
325, 331, 335 Consistency, 68
Colic, 428 Constipation, 27, 7273
Colitis, 428 mechanical factors, 72
Collaboration, 57 perceived, 7475
Colon and rectal cancer, 429 pharmacological factors, 72
Colostomy, 429 physiological factors, 72
Comfort, 5657, 347, 349 psychological facors, 72
enhanced, 5657 risk for, 7677
impaired, 5455 Consultation, 113
level, 12, 120, 136, 177, 232, Contamination
248, 250 accentuated risk factors, 80
measures, 19 definition, 78
Communicable disease, 180 Conversation, 8
management, 81, 95, 181 Coordinated movement, 114,
Communication, 59, 6061, 182, 332, 412
112, 350 Coping, 84, 9293, 102, 110,
enhancement, 6061 136, 159
hearing deficit, 325 behaviors, 317, 319
visual deficit, 335 enhanced, 9293
receptive, 322, 324 ineffective, 8889
Index 475
Coping enhancement, 135, 137, Development, delayed, 106107
157, 159, 255 Developmental care, 199
environmental management, Developmental disorder, 431
273, 337 Developmental enhancement,
Cor pulmonale, 429 22, 163
Coronary artery disease, 429 child, 163, 253
Cough enhancement, 11 Diabetes
Counseling, 75, 103, 113, 159, insipidus, 431
161, 165, 167, 169, 237, management, 154
257, 263, 321, 339 mellitus, 431432
Craniotomy, 429 self-management, 154
Crisis intervention, 79, 275 Diabetic ketoacidosis, 432
Crohns disease, 430 Diarrhea, 108109, 432
Cushings syndrome, 430 Diarrhea management, 109,
Cystic fibrosis, 430 153
Cystitis, 430 Diet plan, 73
Diet staging, 233, 239
D Dignified life closure, 18
Deafness, 430 Digoxin toxicity, 432
Death anxiety, 1819 Discharge planning, 121, 167,
Decision making, 2, 88, 213, 217, 369
100101, 112, 166, 310, Disproportionate growth,
312, 314, 320 164165
enhanced, 100101 Disruptive effects, 248
support, 89, 101, 103, 137, Disseminated intravascular
173, 215, 237, 269, 271, coagulation, 432
289, 291, 309, 311, 315, Dissociative disorder, 432
355, 373, 375, 377 Disuse syndrome, 114115
Decisional conflict, 6263 Diverticulitis, 432
Defensive coping, 8485 Down syndrome, 432
Deficient diversional activity, 8 Dressing/grooming self-care
Deficient fluid volume, 140141 deficit
risk for, 144145 definition, 300
Deficient knowledge, 214215 NIC intervention, 301
Dehydration, 34 Drug
Delusional disorder, 430 addiction, 432433
Dementia, 430431 overdose, 433
management, 123, 225 therapy, 81
Denial, ineffective, 102103 toxicity, 433
Dentition, impaired, 104105 Duodenal ulcer, 433
Depression, 250, 354, 431 Dying patients, 18
control, 172 Dysfunctional family processes
level, 18, 263, 264, 308, 366 (alcoholism), 128129
self-control, 250, 264, 268, Dysfunctional gastrointestinal
406 motility, 150151
Detached retina, 431 risk for, 152153
476 Index
Dysfunctional ventilatory Environmental management, 79,

weaning response, 81, 89, 127, 175, 195,
406407 317, 319, 323, 325, 327,
Dysreflexia management, 25 331, 335, 367, 379, 409
attachment process, 199,
E 253
Ear care, 299 safety, 179, 205, 261, 333,
Eating disorders, 433 415
management, 239, 241 violence prevention, 411
Ectopic pregnancy, 433 Environmental risk protection,
Education, 7, 47 13, 15, 81, 221, 261
Electric pump, 43 Environmental stressors, 17, 22
Electrolyte Esophageal cancer, 434
balance, 143 Esophageal fistula, 434
imbalance, 118119 Esophageal varices, 434
loss, 73 Excess fluid volume, 142143
management, 119, 139, 143, Exercise promotion, 77, 115,
327 135, 149, 241, 245, 321
monitoring, 119, 141, 153, strength training, 5, 7, 227,
391 229, 231, 259, 329, 393,
Emotional coping, 274 413
Emotional feelings, 42 Exercise therapy, 115, 127
Emotional support, 7, 85, 89, ambulation, 369, 413
123, 159, 161, 169, 223, balance, 5, 7, 231, 329, 335,
249, 251, 269, 283, 335, 393
337, 339, 355, 361 joint mobility, 5, 7, 227, 229,
Emphysema, 433 235, 259
Empyema, 433 muscle control, 5, 7, 227,
Encephalitis, 433 229, 231
Endocarditis, 433434
Endometrial cancer, 434 F
Endometriosis, 434 Facilitation, 101, 307
Endurance, 4, 6, 114, 134, 218, Fall prevention, 122, 127, 205,
270, 346, 368, 404, 335, 393, 412
412 Falls occurrence, 394
Energy, 134 Falls, risk for, 126127
conservation, 4, 6, 45, 134, Family, 257
218, 346, 404 coping, 82, 86, 9697, 128,
field disturbance, 120121 130, 132, 156, 282, 374
management, 5, 7, 115, 135, compromised, 8283
149, 173, 209, 215, 219, enhanced, 9697
329, 347, 365, 369, 393, functioning, 106, 112, 128,
413 130, 132, 168, 276, 282,
Environmental interpretation 374
syndrome, impaired, health status, 112, 132
122123 integrity, 112, 116, 132
Index 477
integrity promotion, 107, intake, 27
113, 131, 133, 169, 223, management, 77, 115, 139,
253, 257, 277, 353 141, 143, 145, 147, 149,
integrity promotion 153, 175, 177, 303, 327,
(childbearing family), 333, 343, 379, 395, 399
199, 253 monitoring, 77, 139, 143,
involvement, 375 145, 147, 191, 193, 233,
involvement promotion, 19, 239, 333, 379
83, 87 overload severity, 143
maintenance, 113, 133 replacement therapy, 77
normalization, 82, 87, 96, volume (imbalanced), risk for,
128, 130, 132, 374 146147
participation in professional Fluid balance equillibrium
care, 268, 374 pattern
processes, 132133 definition, 138
enhanced, 132133 `NOC outcomes, 138
interrupted, 130131 Food and fluid intake, 138, 140,
maintenance, 107, 129, 143, 144
131, 254, 255, 295, 375 Food poisoning, 434
management, 97 Foot care, 299, 381
resiliency, 266 Forgiveness facilitation, 263
social climate, 132 Fowlers position, 41, 45
support, 87, 99, 113, 129, Fractures, 434435
131, 133, 157, 169, 215, Frustration, 67
255, 257, 277, 351, 375 Functional urinary incontinence,
therapeutic management, 182183
ineffective, 374375
therapy, 159, 161 G
Fatigue, definition, 134 Gall bladder disease, 435
Fatigue syndrome, chronic, 427 Gas exchange, 148
Fear, 136137 impaired, 148149
control, 136 Gastric cancer, 435
level, 78, 208, 336 Gastric ulcer, 435
self-control, 18, 102, 263 Gastroenteritis, 435
Feeding, 21, 327, 371 Gastrointestinal function, 150
Feeding self-care deficit, Gastrointestinal intubation,
302303 151
Fetal alcohol syndrome, 434 Gastrointestinal perfusion,
Fever, 34 ineffective, 386387
treatment, 175, 379 Genital herpes, 435
Financial resource assistance, 215 Gestational diabetes, 435
Fluid Gestational hypertension, 435
balance, enhanced, 138139 Glaucoma, 435
and electrolyte management, Glomerulonephritis, 435
119, 139, 151, 211, 225, Gonorrhea, 435436
233, 247, 341 Gout, 436
478 Index
Grief facilitation work, 159, Hemorrhoids, 437

161 Hemothorax, 437
Grief resolution, 16, 156, 158, Hepatic coma, 437
160, 310, 358 Hepatitis, 437
Grief work facilitation, 157, Hip fracture, 438
311 Hodgkins disease, 438
Grieving, 29, 156157 Home health nurse, 62
complicated, 158159 Home maintenance
risk for, 160161 assistance, 125, 169, 261
Growth, 106, 162 impaired, 168169
Growth and development, management, 415
delayed, 162163 Hope, 18, 170171, 172, 263,
GuillainBarr syndrome, 436 278, 280, 354, 358
enhanced, 170171
H facilitation, 171
Head injury, 436 installation, 355
Head or neck cancer, 436437 instillation, 265, 283, 307,
Headaches, 436 309, 357, 359, 361
Health Hopelessness, definition, 172
behavior, 74, 214 Human dignity, compromised,
beliefs, 74, 80, 102, 80, 120, 110111
166, 266, 268, 280, 368 Human potential, enhanced, 293
perceived ability to Humidification, 21
perform, 268, 296 Huntingtons disease, 438
education, 75, 79, 81, 91, 95, Hydatidiform mole, 438
155, 167, 205, 215, 237, Hydration, 108, 138, 140, 144,
269, 315 146, 174, 232, 340, 378
maintenance, ineffective, Hydrocephalus, 438
166167 Hyperactivity
orientation, 314, 320 disorder, 423
policy monitoring, 95 level, 16
screening, 81, 91, 155, 163 Hyperbilirubinemia, 438
status, 84, 102, 112, 314 Hyperemesis gravidarum, 438
system guidance, 101, 167 Hyperosmolar hyperglycemic
Healthcare information nonketotic syndrome,
exchange, 215 438
Health-promoting behavior, 96, Hyperparathyroidism, 438
166, 218, 220, 314 Hyperpituitarism, 438
Hearing compensation behavior, Hypertension, 27, 439
322, 324 Hyperthermia, 34, 174175, 439
Heart failure, 437 Hyperthyroidism, 439
Hemodialysis, 437 Hypochondriasis, 439
Hemodynamic regulation, 383, Hypoparathyroidism, 439
391 Hypopituitarism, 439
Hemophilia, 437 Hypothermia, 34, 176177, 439
Hemorrhage, 437 treatment, 177
Index 479
Hypothyroidism, 439 Infertility, 440
Hypovolemia Information processing, 2, 88,
intravenous therapy, 145 214, 270
management, 141, 145, 341 Inhalation injuries, 440
monitoring, 145 Injury, 204205
Insomnia, 208209
I Interstitial pulmonary fibrosis,
ICP monitoring, 211 440
Ileostomy, 439 Intestinal obstruction, 440
Illness, 360 Intoxication, 440
Immobility consequences, 114, Intracranial adaptive capacity,
368 decreased, 210211
physiological, 226, 342, 344 Intravenous therapy, 147, 397
psychocognitive, 226 Isometric exercises, 5, 7, 33
Immune hypersensitivity
response, 12, 14 J
Immune status, 202, 204, 272 Joint movement
Immunization, 81, 95 hip, 228, 392
behavior, 180, 272 knee, 392
status, 180181 mobility, 226
enhanced, 180181 shoulder, 228
vaccination management, 181 spine, 392
Impaction management, 77 Joint replacement, 440
Impotence, 439440 Juvenile rheumatoid arthritis,
Impulse control, 317, 319, 409 440
Impulse control training, 89,
363, 411 K
Impulse self-control, 16, 88, Kangaroo care, 213
178, 263, 316, 318, 356, Kidney function, 143, 390
408, 410 Kidney transplantation, 440
Incision site care, 203, 369 Knowledge, 53, 80, 112, 214,
Individual resilience, impaired, 216217, 360, 372, 374
288289 body mechanics, 392
Infant behavior, disorganized, cardiac disease management,
194195 382
risk for, 196197 cardiac pump effectiveness,
Infant care, 38, 40, 99, 194, 382
196, 198, 199, 213 child development, 196, 198
Infant feeding pattern, circulation status, 382
ineffective, 200201 diabetes management, 154
Infection, 202203 diet, 240, 242, 244
control, 79, 181, 207, 273 disease process, 214
prevention, 37, 345 enhanced, 216217
protection, 203, 221, 343 health behavior, 288, 290,
severity, 174 292
status, 202 health promotion, 216, 390
480 Index
Knowledge (continued) Management (safety), 273

health resources, 214, 256 Maternal-fetal dyad, disturbed,
illness care, 214 116117
infant care, 98, 194 Maternal psychological stress,
infection control, 12, 202, 272 442
parentinfant attachment, 196 Mechanical ventilation, 405
parenting, 98, 256 Meconium aspiration syndrome,
personal safety health, 273 442
treatment procedure(s), 20, Medication administration,
202, 396 335
treatment regimen, 184, 186, intravenous, 397
192, 376, 380 Medication management, 127,
weight management, 242 233, 249, 261
Memory, 2, 122, 224
L impaired, 224225
Labor and delivery, 440 Mnires disease, 442
Lactation counseling, 201 Meningitis, 442
Laryngeal cancer, 441 Menopause, 442
Latex allergy response, 1213 Metabolic acidosis, 442
risk for, 1415 Metabolic alkalosis, 442
Laxatives, 73 Mitral insufficiency, 442
Learning enhancement, 217, Mitral stenosis, 442
255 Mobility, 114, 194, 228, 392,
Learning facilitation, 39, 215, 412
217, 255, 315 level, 230
Leisure participation, 8, 9, 352 Mood
Leukemia, 441 disorders, 442443
Limit setting, 241, 321 equilibrium, 208, 308, 346,
Listening, 16 354, 366
Liver function, impaired, management, 123, 251, 265,
220221 269, 353, 355
Liver transplantation, 441 Moral distress, 112113
Loneliness, 222223 Motivation, 8, 240, 278, 280,
severity, 222, 284, 286, 352 308, 320
Low self-esteem, chronic, Multidisciplinary care
308309 conference, 113, 369
Lung Multiple births, 443
abscess, 441 Multiple myeloma, 443
cancer, 441 Multiple sclerosis, 443
Lupus erythematosus, 441 Multisystem trauma, 443
Lyme disease, 441 Muscular dystrophy, 443
Lymphomas, 441 Mutual goal setting, 173, 235,
239, 255, 297, 315, 321,
M 373
Macular degeneration, 441442 Myasthenia gravis, 443444
Malnutrition, 442 Myocardial infarction, 444
Index 481
N Nutritional monitoring, 125,
Nail care, 299 213, 303, 327
Narcissistic personality disorder, Nutritional status, 72, 124, 134,
444 138, 140, 143, 144, 202,
Nausea, 232233 212, 238, 240, 244, 302,
and vomiting control, 232 344, 368
nutritional management, 233 fluid and food intake, 186,
Neck cancer, 437 200, 232, 238, 242, 326,
Neonatal asphyxia, 444 330, 370
Neonatal hyperbilirubinemia, nutrient intake, 238, 244
444
Neonatal jaundice, 212213 O
Neonate, 194 Obesity, 444
Neurologic impairment Obsessivecompulsive disorder,
(neonatal), 444 444
Neurologic monitoring, 25, 195, Obstructive pulmonary disease,
225, 327, 333, 385 chronic, 427428
Neurologic status, 25, 26, 194, Oral health
196, 198, 206, 384 maintenance, 105, 247, 381
autonomic, 25, 176 promotion, 105
consciousness, 210, 224, 226 restoration, 247
spinal sensory/motor function, Oral hygiene, 104, 246
258, 332 Oral mucous membrane,
Neuromuscular trauma, 444 impaired, 246247
Newborn Organic brain syndrome, 445
care, 53, 195 Organized infant behavior,
monitoring, 197, 213 198199
Noncompliance, 236237 enhanced, 198199
Nonnutritive sucking, 201 Osteoarthritis, 445
Normalization promotion, 107, Osteomyelitis, 445
131 Osteoporosis, 445
spiritual support, 351 Ovarian cancer, 445
Nutrition, 41, 242243 Overdose of drug, 433
enhanced, 242243 Overflow urinary incontinence,
imbalanced 184185
less than body Oxygen therapy, 11, 405
requirements, 238239
more than body P
requirements, 240241, Pain, 248
244245 acute, 248249
management, 75, 77, 107, chronic, 250251, 428
109, 115, 143, 153, 163, control, 248, 250
241, 243, 245, 303, 331, level, 136, 248, 250, 368
333, 369, 381 management, 19, 121, 249,
Nutritional deficiencies, 444 251, 369
Nutritional management, 165 Pain-relieving measures, 54
482 Index
Palate, 428 Personal autonomy, 110, 266,

Pancreatitis, acute, 418 270, 306, 308
Panic disorder, 445 Personal identity, disturbed,
Paralysis, 445 178179
Parent education, 254 Personal potential, enhanced,
adolescent, 205 292
childrearing family, 205 Personal safety behavior, 364,
infant, 195, 197 394, 414
Parent performance, 98 Personality disorders, 446
Parenting, 23, 196, 252253 Phobic disorder, 447
performance, 22, 106, 256, Physical aging, 336, 344
282 status, 124
promotion, 257 Physical maturation
psychosocial, 252 female, 162
Parental role conflict, 6465 male, 162
Parentinfant attachment, 252 Placenta previa, 447
Parenting Planning assistance, 3
enhanced, 252253 Pleural effusion, 447
impaired, 254255, 256257 Pleurisy, 447
Parkinsons disease, 445446 Pneumonia, 447
Patient contracting, 165, 237, Pneumothorax, 447
251, 373 Poisoning, 260261, 447
Patient participation, 29 Polycystic kidney disease, 447
Patient relaxation techniques, Polycythemia vera, 447
17, 23 Positioning, 195, 197, 227, 249,
Patients dignity, 37 343, 345, 371, 381, 405
Patient-child attachment, intraoperative, 207
impaired, 2223 neurologic, 259
Pedal edema, 47 skin surveillance, 389
Pelvic inflammatory disease, 446 wheelchair, 229, 231
Pelvic muscle exercise, 183, 187, Postpartum hemorrhage, 447
189 Posttrauma syndrome, 262263
Perceived control, 266, 312 risk for, 264265
Perinatal trauma, 446 Posttraumatic stress disorder,
Perineal care, 191, 403 448
Perioperative-positioning injury, Power, 266267
206207 enhanced, 266267
Peripheral neurovascular Powerlessness, 268269
dysfunction, 258259 risk for, 270271
Peripheral sensation Preconceptual counseling, 277
management, 259, 333 Pregnancy, 52, 116, 448
Peripheral tissue perfusion, Prematurity, 448
ineffective, 388389 Prenatal health behavior, 116
Peripheral vascular disease, 446 Pressure management, 333, 345,
Peritoneal dialysis, 446 381
Peritonitis, 446 Pressure ulcer, 448
Index 483
care, 343 Reflexes, impaired, 20
prevention, 259, 343, 345, 381 Relationship, 276277
Preterm infant organization, enhanced, 276277
194, 196 Religiosity
Primary intention, 368 enhanced, 280281
Program development, 91 impaired, 278279
Progressive muscle relaxation, readiness for, 282283
329, 347 Religious ritual enhancement,
Prolapsed intervertebral disk, 281, 283
448 Relocation stress syndrome,
Prompted voiding, 183 284285
Prostate cancer, 448 risk for, 286287
Prostatectomy, 448 Renal calculi, 449
Protection of rights, 110 Renal cancer, 449
Protection, ineffective, 272273 Renal disease (end-stage), 450
Pseudomembranous colitis, 448 Renal failure
Psoriasis, 449 acute, 418
Psychomotor energy, 134 chronic, 428
Psychosocial adjustment, 16, Renal tissue perfusion,
124, 158, 266, 312 ineffective, 390391
life change, 16, 156, 284, Resilience, 292293
286, 294, 310 compromised, 290291
Pulmonary edema, 449 effective, 288, 290
Pulmonary embolus, 449 enhanced, 292293
Pyelonephritis, 449 Resiliency promotion, 297
Pyloric stenosis, 449 Respiratory distress syndrome,
450
Q acute, 419
Quality of life, 92, 170, 172, Respiratory failure, acute, 419
250, 263, 278, 280, 284, Respiratory monitoring, 11, 21
286, 308 Respiratory status, 10, 20, 148,
364, 404, 406
R airway patency, 10
Radiation therapy, 449 ventilation, 10, 20, 206, 406
Range of motion (ROM) Respite care, 83
exercises, 4, 6 Rest, 208, 346, 348
Rape, 449 Reyes syndrome, 450
Rape-trauma Risk control, 14, 20, 80, 98, 99,
syndrome, 274275 106, 114, 126, 164, 202,
treatment, 275 204, 212, 222, 243, 244,
Raynauds disease, 449 258, 270, 271, 316, 318,
Reality orientation, 123, 225 320, 334, 344, 356, 364,
Recreation therapy, 9 366, 394, 406
Referral, 167, 217, 357, 371 alcohol, 220
Reflex urinary incontinence, drug use, 220, 260
186187 Rheumatic fever, 450
484 Index
Rheumatoid arthritis, 450 dressing, 300

Risk-prone health behavior, eating, 302
2829 enhanced, 296297
Role enhancement, 22, 116, hygiene, 298, 304, 380
117, 128, 168, 179, 253, instrumental activities of daily
255, 256, 276, 288, 290, living (IADLs), 4, 6
294, 295, 336, 337, 338 oral hygiene, 298
Role performance, ineffective, status, 320
294295 toileting, 182, 304
Role strain, 48 Self-competence, 23
Role-playing strategy, 61 Self-concept, 5, 13, 306307
ROM exercises, 47 enhanced, 306307
Self-confidence, 23
S Self-control, 178, 354
Safe home environment, 122, Self-destructive behavior, 451
220, 260, 394, 414 Self-directed violence, 410411
Safety behavior Self-esteem, 5, 7, 47, 84, 110,
home physical environment, 204 111, 178, 263, 306, 308,
personal, 204 310, 312, 366
Safety status enhancement, 171, 179, 275,
falls occurrence, 204 292, 309, 311, 335
physical injury, 204 Self-harm, 317, 319
Salmonella, 450 Self-health management,
Sarcoidosis, 450 ineffective, 314315
Schizophrenia, 450s Self-modification assistance,
Security enhancement, 137, 209, 221, 267, 313
263 Self-mutilation, 316317
Sedentary lifestyle, 218219 restraint, 316, 318, 356, 410
Seizure disorders, 451 risk for, 318319
Self-advocacy communication, 61 Self-neglect, 320321
Self-assistance, 269, 271 Self-responsibility, 85, 101
Self-awareness enhancement, 85, facilitation, 163, 267, 269,
111, 265, 307, 315, 339 285, 287, 297, 313, 321
Self-care, 168, 296297 Self-restraint, 362
activities, 7, 29, 33, 45, 47, Sensory function
55, 62, 76, 100, 104 cutaneous, 332
activities of daily living hearing, 126
(ADLs), 4, 6, 234, 298, proprioception, 328
300, 302, 304 status, 25
assistance, 183, 235, 299, taste & smell, 322, 326, 330
321, 413 vision, 126, 334
dressing/grooming, 301 Sensory perception, disturbed,
feeding, 303 322323
toileting, 191, 305 auditory, 324325
transfer, 393 gustatory, 326327
bathing, 298 kinesthetic, 328329
Index 485
olfactory, 330331 Social isolation, 352353
tactile, 332333 Social support, 166, 222, 256,
visual, 334335 264, 352, 366
Sepsis, 451 Socialization, 65
Sequence guidance, 3 enhancement, 223, 263, 277,
Sex and counseling, 337 353
Sexual assault, 451 Somatic disorder, 451
Sexual counseling, 277 Speech pattern, 59
Sexual dysfunction, 336337 Spina bifida, 451
Sexual functioning, 276, 336 Spinal cord
Sexual identity, 336, 338 defects, 452
Sexuality patterns, ineffective, injury, 452
338339 Spinal tumor, 452
Shaken baby syndrome, 451 Spiritual distress, 356357
Shock, 451 risk for, 358359
management, 341 Spiritual growth, 279
risk for, 340341 facilitation, 171, 173, 281,
Sickle cell anemia, 451 283, 357, 359, 361
Simple guided imagery, 17 Spiritual health, 112, 120, 166,
Simple massage, 251 264, 278, 280, 358
Simple relaxation therapy, 209 Spiritual needs, 18
Situational low self-esteem, Spiritual support, 19, 125, 223,
310311 279, 281, 283, 289, 291,
risk for, 312313 355, 357, 359, 361
Sjgrens syndrome, 451 Spiritual support family
Skin and mucous membranes, support, 113
138 Spiritual well-being, 360361
Skin integrity, impaired, enhanced, 360361
342343 Splinting, 259, 345
risk for, 344345 Spontaneous ventilation,
Skin surveillance, 109, 207, impaired, 404405
259, 333, 343, 345, 381, Sports injury prevention, 221
397 Spouse abuse, 452
Sleep, 196, 198, 250, 346, Sputum, 11
348349 Stability, 68
activity, 248 Stool softeners, 47
deprivation, 346347 Streptococcal throat, 453
enhancement, 135, 173, 195, Stress
199, 209, 249, 347, level, 16, 214, 240, 244, 263,
348349, 369 264, 284, 286, 326, 336,
patterns, 54 338, 346, 350, 362
thermoregulation, 194 management assistance, 363
Social interaction overload, 362363
impaired, 350351 urinary incontinence,
skills, 8, 9, 16, 33, 84, 88, 188189
130, 222, 276, 350, 352 Stressors, 41
486 Index
Stroke, 453 disease process, 155, 383

Substance abuse consequences, foot care, 381
128 individual, 13, 15, 189
Substance addiction infant nutrition, 213
consequences, 130, 220 prescribed activity/exercise,
Substance use prevention, 107, 219
129, 131 prescribed medications, 155
Substance use treatment, 107, procedure/treatment, 203,
131 215, 397
Suction, 11 Technical aspects of care, 406
Sudden infant death syndrome, Temperature management, 25
9899 Temperature regulation, 175,
Suffering severity, 232 177, 379
Suffocation, 364365 intraoperative, 207
Suicidal behavior, 453 Tendinitis, 453
Suicide, 366367 Testicular cancer, 453
prevention, 367, 411 Therapeutic regimen
self-restraint, 410 management, 376377
Support group, 17, 137, 173, enhanced, 376377
263, 309, 339 ineffective, 372373
Support system enhancement, Therapeutic touch, 121
89, 167, 215, 277, 353, Thermoreceptors, 35
377 Thermoregulation, 34, 174,
Surgical precautions, 207 176, 206, 378
Surgical recovery, delayed, ineffective, 378379
368369 Thoracic surgery, 454
Surveillance, 25, 81, 145, 197, Thought, distorted, 178
213, 221 self-control, 334
safety, 205, 261, 335, 415 Thrombophlebitis, 454
Swallowing status, 20, 200, Time management, 48
302, 370 Tissue integrity, 138
esophageal phase, 370 impaired, 380381
impaired, 370371 skin & mucous membranes,
oral phase, 370 12, 186, 188, 190, 206,
Swallowing therapy, 303, 370, 246, 342, 344, 380, 388,
371 394, 396
Symptom Tissue perfusion
control, 16, 102, 108, 182, abdominal organs, 386
232, 236, 250, 360, 376 cardiac, 382
severity, 346 cerebral, 340, 384
Syphilis, 453 fluid balance, 386
gastrointestinal function,
T 386
Teaching, 75, 105, 127, 217, peripheral, 206, 258, 342,
243 380, 388
Index 487
Toileting, 76, 182 management, 183, 187, 189,
Toileting self-care deficit, 191, 193, 305, 399, 401,
304305 403
Toxicity, drug, 433 Urinary habit training, 183,
Tracheoesophageal fistula, 454 189, 191, 193
Tracheostomy, 454 Urinary retention, 402403
Transfer ability, impaired, care, 185, 399
392393 Urinary tract infection (UTI),
Transfer performance, 228, 392 24, 455
Transient ischemic attacks, 454 Urine-specific gravity, 35
Trauma, 29, 454 Uterine prolapse, 455
risk for, 394395 Uterine rupture, 455
Treatment behavior, 236, 360,
372, 376 V
Treatment regimen, 360, 372 Vaccination management, 81,
Triage, 79 95
Trigeminal neuralgia, 454 Values clarification, 269, 281,
Tube care, 151 283
Tuberculosis, 454 Vascular insufficiency, 455
Turning and repositioning, 5, 6, Vascular trauma, 396397
19, 45, 47 Ventilation, 11, 148, 364,
404
U assistance, 11
Unilateral neglect, 234235 Verbal communication,
management, 235 impaired, 5859
Unstable blood glucose, Violence prevention, 409
154155 Viral hepatitis, 455
Urge urinary incontinence, Vision compensation behavior,
190191 334
risk for, 192193 Visitation facilitation, 223
Urinary bladder training, 187, Vital signs, 138, 146, 148, 174,
403 176, 340, 378, 404, 406
Urinary calculi, 454 monitoring, 21, 25, 177, 213,
Urinary catheterization, 403 365, 379
Urinary continence, 182, 184, status, 25
186, 188, 190, 192, 398, Vomiting management, 21
400, 402, 454
care, 185, 187, 189, 191, W
193 Walking, impaired, 412413
Urinary diversion, 454 Wandering, 414415
Urinary elimination, 144, 182, Water intake, 11
186, 188, 190, 192, 398, Weight (body mass), 164
400401, 402 Weight control, 154, 238, 240,
enhanced, 400401 244
impaired, 398399 Weight goal-setting, 239
488 Index
Weight management, 109, 265, Wound care, 203, 343

243, 321, 399 Wound healing, 368
Weight reduction assistance, 241 primary intention, 202, 210,
Wheelchair mobility, impaired, 342
230231 secondary intention, 202,
Will to live, 124, 170 342, 380

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What is the purpose of the book?

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What topics are covered in the book?

LWBK392-FM_i-xxiv.

qxd 11/17/09 8:20 PM Page i Aptara Inc

SPARKS AND TAYLORS

Sheila Sparks Ralph, RN, PhD, FAAN

Cynthia M. Taylor, RN, MS

Acquisitions Editor: Jean Rodenberger

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Library of Congress Cataloging-in-Publication Data

Marcia Perkins, MSN, RN

Helen H. Mautner, MSN, RN

Anne Z. Cockerham, PhD, CNM

Jennifer Matthews, PhD, RN

Billinda Tebbenhoff, MSN, RN

Sherry Rawls-Bryce, MSN, RN

Maryann Valcourt, MSN, CPNP

For student nurses as well as expert clinicians, Sparks and Taylors

GUIDELINES FOR USING SPARKS AND TAYLORS NURSING

NURSING PROCESS OVERVIEW

Collecting Subjective and Objective Data

functions of body systems. Using IPPA skills effectively lessens the

diagnostic test (schedule for cardiac angiography)

At first, these distinctions may not be clear. The following examples

Dont state a need instead of a problem.

Incorrect: Inability to speak related to laryngectomy

Selecting appropriate nursing actions (interventions): Next, youll

Understanding Nursing Interventions Classification

Select evaluation criteria. The care plans projected outcomesthe

DESCRIPTION OF NNN TAXONOMY OF NURSING

We would like to express our sincere appreciation to the nurses who

Sheila Sparks Ralph, RN, PhD, FAAN

Guidelines for Using Sparks and Taylors Nursing Diagnosis

Nursing Process Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Description of NNN Taxonomy of Nursing Practice

APPENDIX B Taxonomy of Nursing Practice: A Common

APPENDIX C Action Intervention Types . . . . . . . . . . . . . . . 470

INEFFECTIVE ACTIVITY PLANNING

RISK FOR ACTIVITY INTOLERANCE

DEFICIENT DIVERSIONAL ACTIVITY

INEFFECTIVE AIRWAY CLEARANCE

LATEX ALLERGY RESPONSE

RISK FOR LATEX ALLERGY RESPONSE

RISK FOR ASPIRATION

RISK FOR IMPAIRED PARENTCHILD

RISK FOR AUTONOMIC DYSREFLEXIA

RISK-PRONE HEALTH BEHAVIOR

RISK FOR BLEEDING

DISTURBED BODY IMAGE

RISK FOR IMBALANCED BODY TEMPERATURE

INEFFECTIVE BREATHING PATTERN

DECREASED CARDIAC OUTPUT

CAREGIVER ROLE STRAIN

RISK FOR CAREGIVER ROLE STRAIN

READINESS FOR ENHANCED

READINESS FOR ENHANCED COMFORT

IMPAIRED VERBAL COMMUNICATION