119663657-Nursing Diagnosis Care Plans

NURSING DIAGNOSIS
Table of Contents
NURSING .................................................................................................1 DIAGNOSIS..............................................................................................1 Table of Contents....................................................................................2 Activity Intolerance Weakness Decon!itione! Se!entary.............................................1"
On#oin# Assess$ent..........................................................................11 T%era&e'tic Interventions...................................................................12 (!'cation)Contin'ity of Care..............................................................1*
Ineffective air+ay clearance..................................................................1,

NIC Interventions -N'rsin# Interventions Classification......................1, On#oin# Assess$ent..........................................................................1/ T%era&e'tic Interventions...................................................................10 (!'cation)Contin'ity of Care..............................................................11
Risk for As&iration.................................................................................21

NOC O'tco$es -N'rsin# O'tco$es Classification..............................21 NIC Interventions -N'rsin# Interventions Classification......................21 On#oin# Assess$ent..........................................................................22 T%era&e'tic Interventions...................................................................22 (!'cation)Contin'ity of Care..............................................................2,
An2iety..................................................................................................2,
NIC Interventions -N'rsin# Interventions Classification......................2, On#oin# Assess$ent..........................................................................2/ T%era&e'tic Interventions...................................................................23 (!'cation)Contin'ity of Care..............................................................20
Decrease! Car!iac O't&'t....................................................................24

NOC O'tco$es -N'rsin# O'tco$es Classification..............................24 NIC Interventions -N'rsin# Interventions Classification......................24 On#oin# Assess$ent..........................................................................21 T%era&e'tic Interventions...................................................................*1
(!'cation)Contin'ity of Care..............................................................*2
Ineffective 5reat%in# 6attern................................................................*2

NOC O'tco$es -N'rsin# O'tco$es Classification..............................*2 NIC Interventions -N'rsin# Interventions Classification......................** On#oin# Assess$ent..........................................................................*, T%era&e'tic Interventions...................................................................*/ (!'cation)Contin'ity of Care..............................................................*0
Dist'rbe! 5o!y I$a#e...........................................................................*0

NOC O'tco$es -N'rsin# O'tco$es Classification..............................*4 NIC Interventions -N'rsin# Interventions Classification......................*4 On#oin# Assess$ent..........................................................................*1 T%era&e'tic Interventions...................................................................," (!'cation)Contin'ity of Care..............................................................,"
Ineffective Co&in#.................................................................................,1
NOC O'tco$es -N'rsin# O'tco$es Classification..............................,1 NIC Interventions -N'rsin# Interventions Classification......................,1 On#oin# Assess$ent..........................................................................,2 T%era&e'tic Interventions...................................................................,* (!'cation)Contin'ity of Care..............................................................,,
Diarr%ea 7oose Stools8 Clostri!i'$ !ifficile -C. !ifficile..................................,/

NOC O'tco$es -N'rsin# O'tco$es Classification..............................,/ NIC Interventions -N'rsin# Interventions Classification......................,3 On#oin# Assess$ent..........................................................................,0 T%era&e'tic Interventions...................................................................,4 (!'cation)Contin'ity of Care..............................................................,1
Deficient 9l'i! :ol'$e ;y&ovole$ia De%y!ration............................................................../"

NOC O'tco$es -N'rsin# O'tco$es Classification............................../" NIC Interventions -N'rsin# Interventions Classification....................../" On#oin# Assess$ent........................................................................../1 T%era&e'tic Interventions.................................................................../2 (!'cation)Contin'ity of Care............................................................../*
I$&aire! Gas (2c%an#e :entilation or 6erf'sion I$balance................................................../,

NOC O'tco$es -N'rsin# O'tco$es Classification............................../, NIC Interventions -N'rsin# Interventions Classification....................../, On#oin# Assess$ent........................................................................../3 T%era&e'tic Interventions.................................................................../0 (!'cation)Contin'ity of Care............................................................../1
Ineffective ;ealt% <aintenance............................................................./1

NOC O'tco$es -N'rsin# O'tco$es Classification............................../1 NIC Interventions -N'rsin# Interventions Classification....................../1 On#oin# Assess$ent..........................................................................31 T%era&e'tic Interventions...................................................................3* (!'cation)Contin'ity of Care..............................................................3*
Risk for Infection Universal 6reca'tions Stan!ar! 6reca'tions CDC G'i!elines OS;A3,
NOC O'tco$es -N'rsin# O'tco$es Classification..............................3, NIC Interventions -N'rsin# Interventions Classification......................3, On#oin# Assess$ent..........................................................................3/ T%era&e'tic Interventions...................................................................33 (!'cation)Contin'ity of Care..............................................................30
I$&aire! 6%ysical <obility I$$obility........................................................................................34

NOC O'tco$es -N'rsin# O'tco$es Classification..............................34 NIC Interventions -N'rsin# Interventions Classification......................34 On#oin# Assess$ent..........................................................................0" T%era&e'tic Interventions...................................................................01 (!'cation)Contin'ity of Care..............................................................0*
Nonco$&liance =no+le!#e Deficit 6atient (!'cation..............................................0*

NOC O'tco$es -N'rsin# O'tco$es Classification..............................0* NIC Interventions -N'rsin# Interventions Classification......................0* On#oin# Assess$ent..........................................................................0/ T%era&e'tic Interventions...................................................................03
(!'cation)Contin'ity of Care..............................................................00
I$balance! N'trition> 7ess t%an 5o!y Re?'ire$ents Starvation Wei#%t 7oss Anore2ia...................................................00
NOC O'tco$es -N'rsin# O'tco$es Classification..............................00 NIC Interventions -N'rsin# Interventions Classification......................00 On#oin# Assess$ent..........................................................................04 T%era&e'tic Interventions...................................................................01 (!'cation)Contin'ity of Care..............................................................41
I$balance! N'trition> <ore t%an 5o!y Re?'ire$ents Obesity Over+ei#%t........................................................................41

NOC O'tco$es -N'rsin# O'tco$es Classification..............................41 NIC Interventions -N'rsin# Interventions Classification......................41 On#oin# Assess$ent..........................................................................42 T%era&e'tic Interventions...................................................................4* (!'cation)Contin'ity of Care..............................................................4/
Ac'te 6ain.............................................................................................43
NOC O'tco$es -N'rsin# O'tco$es Classification..............................43 NIC Interventions -N'rsin# Interventions Classification......................43 On#oin# Assess$ent..........................................................................40 T%era&e'tic Interventions...................................................................1" (!'cation)Contin'ity of Care..............................................................12
C%ronic 6ain..........................................................................................1*
NOC O'tco$es -N'rsin# O'tco$es Classification..............................1* NIC Interventions -N'rsin# Interventions Classification......................1* On#oin# Assess$ent..........................................................................1, T%era&e'tic Interventions...................................................................13 (!'cation)Contin'ity of Care..............................................................10
Self@Care Deficit 5at%in#);y#iene Dressin#)Groo$in# 9ee!in# Toiletin#...............11

NOC O'tco$es -N'rsin# O'tco$es Classification..............................11 NIC Interventions -N'rsin# Interventions Classification......................11 On#oin# Assess$ent........................................................................1"" T%era&e'tic Interventions.................................................................1"1
(!'cation)Contin'ity of Care............................................................1"3
Risk for I$&aire! Skin Inte#rity 6ress're Sores 6ress're Ulcers 5e! Sores Dec'bit's Care........1"3
NOC O'tco$es -N'rsin# O'tco$es Classification............................1"3 NIC Interventions -N'rsin# Interventions Classification....................1"3 On#oin# Assess$ent........................................................................1"0 T%era&e'tic Interventions.................................................................1"1 (!'cation)Contin'ity of Care............................................................11"
Dist'rbe! Slee& 6attern Inso$nia........................................................................................111

NOC O'tco$es -N'rsin# O'tco$es Classification............................111 NIC Interventions -N'rsin# Interventions Classification....................111 On#oin# Assess$ent........................................................................11* T%era&e'tic Interventions.................................................................11* (!'cation)Contin'ity of Care............................................................11/
Ineffective T%era&e'tic Re#i$en <ana#e$ent...................................11/

NIC Interventions -N'rsin# Interventions Classification....................11/ On#oin# Assess$ent........................................................................113 T%era&e'tic Interventions.................................................................110 (!'cation)Contin'ity of Care............................................................114
Dist'rbe! Sensory 6erce&tion> A'!itory ;earin# 7oss ;earin# I$&aire! Deafness....................................111

NOC O'tco$es -N'rsin# O'tco$es Classification............................111 NIC Interventions -N'rsin# Interventions Classification....................111 On#oin# Assess$ent........................................................................12" T%era&e'tic Interventions.................................................................122 (!'cation)Contin'ity of Care............................................................12*
Dist'rbe! Sensory 6erce&tion> :is'al :ision 7oss <ac'lar De#eneration 5lin!ness..............................12,

NOC O'tco$es -N'rsin# O'tco$es Classification............................12, NIC Interventions -N'rsin# Interventions Classification....................12, On#oin# Assess$ent........................................................................123 T%era&e'tic Interventions.................................................................120
(!'cation)Contin'ity of Care............................................................124
Urinary Retention................................................................................121
NOC O'tco$es -N'rsin# O'tco$es Classification............................121 NIC Interventions -N'rsin# Interventions Classification....................1*" On#oin# Assess$ent........................................................................1*1 T%era&e'tic Interventions.................................................................1*1 (!'cation)Contin'ity of Care............................................................1*2
Ineffective Tiss'e 6erf'sion> 6eri&%eral8 Renal8 Gastrointestinal8 Car!io&'l$onary8 Cerebral.........................................................................................1**

NOC O'tco$es -N'rsin# O'tco$es Classification............................1** NIC Interventions -N'rsin# Interventions Classification....................1*, On#oin# Assess$ent........................................................................1*3 T%era&e'tic Interventions.................................................................1*0 S&ecific Interventions.......................................................................1*0 (!'cation)Contin'ity of Care............................................................1*1
I$&aire! :erbal Co$$'nication.........................................................1*1

NOC O'tco$es -N'rsin# O'tco$es Classification............................1*1 NIC Interventions -N'rsin# Interventions Classification....................1*1 On#oin# Assess$ent........................................................................1,1 T%era&e'tic Interventions.................................................................1,* (!'cation)Contin'ity of Care............................................................1,/
(2cess 9l'i! :ol'$e ;y&ervole$ia 9l'i! Overloa!.......................................................1,3

NOC O'tco$es -N'rsin# O'tco$es Classification............................1,3 NIC Interventions -N'rsin# Interventions Classification....................1,3 On#oin# Assess$ent........................................................................1,4 T%era&e'tic Interventions.................................................................1,1 (!'cation)Contin'ity of Care............................................................1/1
Activity/Rest Activity intolerance (specify level) Activity intolerance, for Disuse syndrome, risk for Divisional activity deficit Fatigue
Sleep pattern disturbance Circulation Adaptive capacity intracranial, decreased Cardiac output, decreased Dysrefle!ia
"issue perfusion, altered (specify) cerebral, cardiopulmonary, renal, gastrointestinal, perip#eral $go %ntegrity Ad&ustment, impaired An!iety (mild, moderate, severe, panic) 'ody image disturbance Coping, defensive Coping, individual, ineffective Decisional conflict Denial, ineffective $nergy field disturbance Fear (rieving, anticipatory (rieving, dysfunctional )opelessness *ersonal identity disturbance *ost+trauma response (specify stage) *o,erlessness Rape+trauma syndrome (specify) Rape+trauma syndrome compound reaction Rape+trauma syndrome silent reaction Relocation stress syndrome Self+esteem, c#ronic lo, Self+esteem disturbance Self+esteem, situational lo, Spiritual distress (distress of t#e #uman spirit) Spiritual ,ell being, en#anced, potential for $limination 'o,el incontinence Constipation Constipation, colonic Constipation, perceived Diarr#ea %ncontinence, functional %ncontinence, refle! %ncontinence, stress %ncontinence, total %ncontinence, urge -rinary elimination, altered -rinary retention, (acute/c#ronic) Food/ Fluid 'reastfeeding, effective
'reastfeeding, ineffective 'reastfeeding, interrupted Fluid volume deficit (active loss) Fluid volume deficit (regulatory failure) Fluid volume deficit, risk for Fluid volume e!cess %nfant feeding pattern, ineffective .utrition altered, less t#an body re/uirements .utrition altered, more t#an body re/uirements .utrition altered, risk for more t#an body re/uirements 0ral mucous membrane, altered S,allo,ing, impaired )ygiene Self+care deficit (specify level) feeding, bat#ing/#ygiene, dressing/ grooming, toileting .eurosensory Confusion, acute Confusion, c#ronic %nfant be#avior, disorgani1ed %nfant be#avior, disorgani1ed, risk for %nfant be#avior, organi1ed, potential for en#anced 2emory, impaired *erip#eral neurovascular dysfunction, risk for Sensory perception alterations (specify) visual, auditory, kinest#etic, gustatory, tactile, olfactory "#oug#t processes, altered -nilateral neglect *ain/Discomfort *ain *ain, acute *ain, c#ronic Respiration Air,ay clearance, ineffective Aspiration, risk for 'reat#ing pattern, ineffective (as e!c#ange, impaired Spontaneous ventilation, inability to sustain 3entilator ,eaning response, dysfunctional (D34R) Safety 'ody temperature, altered, risk for $nvironmental interpretation syndrome, impaired )ealt# maintenance, altered
)ome maintenance management, impaired )ypert#ermia )ypot#ermia %nfection, risk for %n&ury, risk for *erioperative positioning in&ury, risk for *#ysical mobility, impaired *oisoning, risk for *rotection, altered Self+mutilation, risk for Skin integrity, impaired Skin integrity, impaired, risk for Suffocation, risk for "#ermoregulation, ineffective "issue integrity, impaired "rauma, risk for 3iolence, (actual)/risk for directed at self/ot#ers Se!uality(component of ego integrity and social interaction) Se!ual dysfunction Se!uality patterns, altered Social %nteraction Caregiver role strain Caregiver role strain, risk for Communication, impaired verbal Community coping, en#anced, potential for Community coping, ineffective Family coping, ineffective Family coping, potential for gro,t# Family processes, altered alco#olism (substance abuse) Family processes, altered 5oneliness, risk for *arental role conflict *arent/infant/c#ild attac#ment, altered, risk for *arenting, altered *arenting, altered, risk for Role performance, altered Social interaction, impaired Social isolation "eac#ing/5earning (ro,t# and development, altered )ealt#+seeking be#aviors (specify)
6no,ledge deficit (learning need) (specify) .oncompliance (compliance, altered) (specify) "#erapeutic regimen community, ineffective management "#erapeutic regimen families, ineffective management "#erapeutic regimen individual, effective management "#erapeutic regimen individual, ineffective management
Activity Intolerance
Weakness; Deconditioned; Sedentary NANDA Definition: %nsufficient p#ysiological or psyc#ological energy to endure or complete re/uired or desired daily activities 2ost activity intolerance is related to generali1ed ,eakness and debilitation secondary to acute or c#ronic illness and disease7 "#is is especially apparent in elderly patients ,it# a #istory of ort#opedic, cardiopulmonary, diabetic, or pulmonary+ related problems7 "#e aging process itself causes reduction in muscle strengt# and function, ,#ic# can impair t#e ability to maintain activity7 Activity intolerance may also be related to factors suc# as obesity, malnouris#ment, side effects of medications (e7g7, +blockers), or emotional states suc# as depression or lack of confidence to e!ert one8s self7 .ursing goals are to reduce t#e effects of inactivity, promote optimal p#ysical activity, and assist t#e patient to maintain a satisfactory lifestyle7 Defining C aracteristics: 3erbal report of fatigue or ,eakness, %nability to begin or perform activity, abnormal #eart rate or blood pressure ('*) response to activity, $!ertional discomfort or dyspnea Related !actors: (enerali1ed ,eakness, Deconditioned state, Sedentary lifestyle, %nsufficient sleep or rest periods, Depression or lack of motivation, *rolonged bed rest, %mposed activity restriction, %mbalance bet,een o!ygen supply and demand, *ain, Side effects of medications "#$ected O%tco&es + *atient maintains activity level ,it#in capabilities, as evidenced by normal #eart rate and blood pressure during activity, as ,ell as absence of s#ortness of breat#, ,eakness, and fatigue7 *atient verbali1es and uses energy+conservation tec#ni/ues7
9:
Ongoing Assess&ent
Determine patient8s perception of causes of fatigue or activity intolerance7 T ese &ay be te&$orary or $er&anent' $ ysical or $syc ological( Assess&ent g%ides treat&ent( Assess patient8s level of mobility7 T is aids in defining ) at $atient is ca$able of' ) ic is necessary before setting realistic goals( Assess nutritional status7 Ade*%ate energy reser+es are re*%ired for acti+ity( Assess potential for p#ysical in&ury ,it# activity7 In,%ry &ay be related to falls or o+ere#ertion( Assess need for ambulation aids bracing, cane, ,alker, e/uipment modification for activities of daily living (AD5s)7 So&e aids &ay re*%ire &ore energy e#$endit%re for $atients ) o a+e red%ced %$$er ar& strengt -e(g(' )alking )it cr%tc es.( Ade*%ate assess&ent of energy re*%ire&ents is indicated(
Assess patient8s cardiopulmonary status before activity using t#e follo,ing measures
)eart rate /eart rate s o%ld not increase &ore t an 01 to 21 beats3&in abo+e resting )it ro%tine acti+ities( T is n%&ber )ill c ange de$ending on t e intensity of e#ercise t e $atient is atte&$ting -e(g(' cli&bing fo%r flig ts of stairs +ers%s s o+eling sno).( 0rt#ostatic '* c#anges "lderly $atients are &ore $rone to dro$s in blood $ress%re )it $osition c anges( .eed for o!ygen ,it# increased activity 4ortable $%lse o#i&etry can be %sed to assess for o#ygen desat%ration( S%$$le&ental o#ygen &ay el$ co&$ensate for t e increased o#ygen de&ands( )o, 3alsalva maneuver affects #eart rate ,#en patient moves in bed 5alsal+a &ane%+er' ) ic re*%ires breat cardiac o%t$%t(
olding and bearing do)n' can ca%se bradycardia and related red%ced
2onitor patient8s sleep pattern and amount of sleep ac#ieved over past fe, days7 Diffic%lties slee$ing need to be addressed before acti+ity $rogression can be ac ie+ed( 0bserve and document response to activity7 Report any of t#e follo,ing
99
Rapid pulse (;: beats/min over resting rate or 9;: beats/min) *alpitations Significant increase in systolic '* (;: mm )g) Significant decrease in systolic '* (;: mm )g) Dyspnea, labored breat#ing, ,#ee1ing 4eakness, fatigue 5ig#t#eadedness, di11iness, pallor, diap#oresis
Close &onitoring ser+es as a g%ide for o$ti&al $rogression of acti+ity(
Assess emotional response to c#ange in p#ysical status7 De$ression o+er inability to $erfor& re*%ired acti+ities can f%rt er aggra+ate t e acti+ity intolerance(
T era$e%tic Inter+entions
$stablis# guidelines and goals of activity ,it# t#e patient and caregiver7 6oti+ation is en anced if t e $atient $artici$ates in goal setting( De$ending on t e etiological factors of t e acti+ity intolerance' so&e $atients &ay be able to li+e inde$endently and )ork o%tside t e o&e( Ot er $atients )it c ronic debilitating disease &ay re&ain o&ebo%nd(
$ncourage ade/uate rest periods, especially before meals, ot#er AD5s, e!ercise sessions, and ambulation7 Rest bet)een acti+ities $ro+ides ti&e for energy conser+ation and reco+ery( /eart rate reco+ery follo)ing acti+ity is greatest at t e beginning of a rest $eriod(
Refrain from performing nonessential procedures7 4atients )it li&ited acti+ity tolerance need to $rioriti7e tasks( Anticipate patient8s needs (e7g7, keep telep#one and tissues ,it#in reac#)7 Assist ,it# AD5s as indicated< #o,ever, avoid doing for patient ,#at #e or s#e can do for self7 Assisting t e $atient )it AD8s allo)s for conser+ation of energy( Caregi+ers need to balance $ro+iding assistance )it facilitating $rogressi+e end%rance t at )ill %lti&ately en ance t e $atient9s acti+ity tolerance and self:estee&(
9;
*rovide bedside commode as indicated7 T is red%ces energy e#$endit%re( NOT": A bed$an re*%ires &ore energy t an a co&&ode( $ncourage p#ysical activity consistent ,it# patient8s energy resources7 Assist patient to plan activities for times ,#en #e or s#e #as t#e most energy7 Not all self: care and ygiene acti+ities need to be co&$leted in t e &orning( 8ike)ise' not all o%secleaning needs to be co&$leted in ; day(
$ncourage verbali1ation of feelings regarding limitations7 Ackno)ledg&ent t at li+ing )it acti+ity intolerance is bot $ ysically and e&otionally diffic%lt aids co$ing( *rogress activity gradually, as ,it# t#e follo,ing Active range+of+motion (R02) e!ercises in bed, progressing to sitting and standing, Dangling 9: to 9= minutes t#ree times daily, Deep breat#ing e!ercises t#ree times daily, Sitting up in c#air >: minutes t#ree times daily, 4alking in room 9 to ; minutes t#ree times daily, 4alking in #all ;= feet or ,alking around t#e #ouse, t#en slo,ly progressing, saving energy for return trip T is $re+ents o+ere#erting t e eart and $ro&otes attain&ent of s ort:range goals(
$ncourage active R02 e!ercises t#ree times daily7 %f furt#er reconditioning is needed, confer ,it# re#abilitation personnel7 "#ercises &aintain &%scle strengt and ,oint RO6(
*rovide emotional support ,#ile increasing activity7 *romote a positive attitude regarding abilities7 $ncourage patient to c#oose activities t#at gradually build endurance7 %mprovise in adapting AD5 e/uipment or environment7 A$$ro$riate aids )ill enable t e $atient to ac ie+e o$ti&al inde$endence for self:care(
"d%cation3Contin%ity of Care
"eac# patient/caregivers to recogni1e signs of p#ysical overactivity7 T is $ro&otes a)areness of ) en to red%ce acti+ity( %nvolve patient and caregivers in goal setting and care planning7 Setting s&all' attainable goals can increase self:confidence and self:estee&( 4#en #ospitali1ed, encourage significant ot#ers to bring ambulation aid (e7g7, ,alker or cane)7
9>
"eac# t#e importance of continued activity at #ome7 T is &aintains strengt ' RO6' and end%rance gain( Assist in assigning priority to activities to accommodate energy levels7 "eac# energy conservation tec#ni/ues7 Some e!amples include t#e follo,ing Sitting to do tasks Standing re*%ires &ore )ork( C#anging positions often T is distrib%tes )ork to different &%scles to a+oid fatig%e( *us#ing rat#er t#an pulling, Sliding rat#er t#an lifting, 4orking at an even pace T is allo)s eno%g ti&e so not all )ork is co&$leted in a s ort $eriod( Storing fre/uently used items ,it#in easy reac# T is a+oids bending and reac ing( Resting for at least 9 #our after meals before starting a ne, activity "nergy is needed to digest food( -sing ,#eeled carts for laundry, s#opping, and cleaning needs 0rgani1ing a ,ork+rest+ ,ork sc#edule T ese red%ce o#ygen cons%&$tion' allo)ing &ore $rolonged acti+ity( "eac# appropriate use of environmental aids (e7g7, bed rails, elevating #ead of bed ,#ile patient gets out of bed, c#air in bat#room, #all rails)7 T ese conser+e energy and $re+ent in,%ry fro& fall(
"eac# R02 and strengt#ening e!ercises7 $ncourage patient to verbali1e concerns about disc#arge and #ome environment7 T ese red%ce feelings of an#iety and fear( Refer to community resources as indicated7
Ineffecti+e air)ay clearance

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels
Coug# $n#ancement
Air,ay 2anagement
Air,ay Suctioning
NANDA Definition: %nability to clear secretions or obstructions from t#e respiratory tract to maintain air,ay patency
9?
2aintaining a patent air,ay is vital to life7 Coug#ing is t#e main mec#anism for clearing t#e air,ay7 )o,ever, t#e coug# may be ineffective in bot# normal and disease states secondary to factors suc# as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular ,eakness7 0t#er mec#anisms t#at e!ist in t#e lo,er bronc#ioles and alveoli to maintain t#e air,ay include t#e mucociliary system, macrop#ages, and t#e lymp#atics7 Factors suc# as anest#esia and de#ydration can affect function of t#e mucociliary system7 5ike,ise, conditions t#at cause increased production of secretions (e7g7, pneumonia, bronc#itis, and c#emical irritants) can overta! t#ese mec#anisms7 %neffective air,ay clearance can be an acute (e7g7, postoperative recovery) or c#ronic (e7g7, from cerebrovascular accident @C3AA or spinal cord in&ury) problem7 $lderly patients, ,#o #ave an increased incidence of emp#ysema and a #ig#er prevalence of c#ronic coug# or sputum production, are at #ig# risk7 Defining C aracteristics: Abnormal breat# sounds (crackles, r#onc#i, ,#ee1es), C#anges in respiratory rate or dept#, Coug#, )ypo!emia/cyanosis, Dyspnea, C#est ,#ee1ing, Fever, "ac#ycardia,
Related !actors: Decreased energy and fatigue, %neffective coug#, trac#eobronc#ial infection, "rac#eobronc#ial obstruction (including foreign body aspiration), Copious trac#eobronc#ial secretions, *erceptual/cognitive impairment, %mpaired respiratory muscle function, "rauma "#$ected O%tco&es: *atient8s secretions are mobili1ed and air,ay is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively coug# up secretions after treatments and deep breat#s7 Ongoing Assess&ent
Assess air,ay for patency7 6aintaining t e air)ay is al)ays t e first $riority' es$ecially in cases of tra%&a' ac%te ne%rological deco&$ensation' or cardiac arrest( Auscultate lungs for presence of normal or adventitious breat# sounds, as in t#e follo,ing Decreased or absent breat# sounds7 T ese &ay indicate $resence of &%c%s $l%g or ot er &a,or air)ay obstr%ction( 9=
4#ee1ing7 T ese &ay indicate increasing air)ay resistance( Coarse sounds7 T ese &ay indicate $resence of fl%id along larger air)ays( Assess respirations< note /uality, rate, pattern, dept#, flaring of nostrils, dyspnea on e!ertion, evidence of splinting, use of accessory muscles, and position for breat#ing7 Abnor&ality indicates res$iratory co&$ro&ise(
Assess c#anges in mental status7 Increasing let argy' conf%sion' restlessness' and3or irritability can be early signs of cerebral y$o#ia( Assess c#anges in vital signs and temperature7 Tac ycardia and y$ertension &ay be related to increased )ork of breat ing( !e+er &ay de+elo$ in res$onse to retained secretions3atelectasis(
Assess coug# for effectiveness and productivity7 Consider $ossible ca%ses for ineffecti+e co%g -e(g(' res$iratory &%scle fatig%e' se+ere bronc os$as&' or t ick tenacio%s secretions.(
.ote presence of sputum< assess /uality, color, amount, odor, and consistency7 T is &ay be a res%lt of infection' bronc itis' c ronic s&oking' or ot er condition( A sign of infection is discolored s$%t%& -no longer clear or ) ite.; an odor &ay be $resent( Send a sputum specimen for culture and sensitivity as appropriate7 Res$iratory infections increase t e )ork of breat ing; antibiotic treat&ent is indicated(
2onitor arterial blood gases (A'(s)7 Increasing 4aCO0 and decreasing 4aO0 are signs of res$iratory fail%re( Assess for pain7 4osto$erati+e $ain can res%lt in s allo) breat ing and an ineffecti+e co%g ( %f patient is on mec#anical ventilation, monitor for peak air,ay pressures and air,ay resistance7 Increases in t ese $ara&eters signal acc%&%lation of secretions3 fl%id and $ossibility for ineffecti+e +entilation(
Assess patientBs kno,ledge of disease process7 4atient ed%cation )ill +ary de$ending on t e ac%te or c ronic disease state as )ell as t e $atient<s cogniti+e le+el(
9C
Assist patient in performing coug#ing and breat#ing maneuvers7 T ese i&$ro+e $rod%cti+ity of t e co%g ( %nstruct patient in t#e follo,ing

0ptimal positioning (sitting position) -se of pillo, or #and splints ,#en coug#ing -se of abdominal muscles for more forceful coug# -se of /uad and #uff tec#ni/ues -se of incentive spirometry %mportance of ambulation and fre/uent position c#anges
Directed co%g ing tec ni*%es el$ &obili7e secretions fro& s&aller air)ays to larger air)ays beca%se t e co%g ing is done at +arying ti&es( T e sitting $osition and s$linting t e abdo&en $ro&ote &ore effecti+e co%g ing by increasing abdo&inal $ress%re and %$)ard dia$ rag&atic &o+e&ent(
-se positioning (if tolerated, #ead of bed at ?= degrees< sitting in c#air, ambulation)7 T ese $ro&ote better l%ng e#$ansion and i&$ro+ed air e#c ange( %f patient is bedridden, routinely c#eck t#e patientBs position so #e or s#e does not slide do,n in bed7 T is &ay ca%se t e abdo&en to co&$ress t e dia$ rag&' ) ic )o%ld ca%se res$iratory e&barrass&ent(
%f coug# is ineffective, use nasotrac#eal suctioning as needed

$!plain procedure to patient7 -se soft rubber cat#eters7 T is $re+ents tra%&a to &%co%s &e&branes( -se curved+tip cat#eters and #ead positioning (if not contraindicated)7 T ese facilitate secretion re&o+al fro& a s$ecific side -rig t +ers%s left l%ng.( %nstruct t#e patient to take several deep breat#s before and after eac# nasotrac#eal suctioning procedure and use supplemental o!ygen as appropriate7 T is $re+ents s%ction:related y$o#ia(
9D
Stop suctioning and provide supplemental o!ygen (assisted breat#s by Ambu bag as needed) if t#e patient e!periences bradycardia, an increase in ventricular ectopy, and/or desaturation7
-se universal precautions gloves, goggles, and mask as appropriate7 If s$%t%& is $%r%lent' $reca%tions s o%ld be instit%ted before recei+ing t e c%lt%re and sensiti+ity re$ort(
S%ctioning is indicated ) en $atients are %nable to re&o+e secretions fro& t e air)ays by co%g ing beca%se of )eakness' t ick &%c%s $l%gs' or e#cessi+e &%c%s $rod%ction(
%nstitute appropriate isolation precautions for positive cultures (e7g7, met#icillin+resistant Staphylococcus aureus @2RSAA or tuberculosis)7 -se #umidity (#umidified o!ygen or #umidifier at bedside)7 T is loosens secretions( $ncourage oral intake of fluids ,it#in t#e limits of cardiac reserve7 Increased fl%id intake red%ces t e +iscosity of &%c%s $rod%ced by t e goblet cells in t e air)ays( It is easier for t e $atient to &obili7e t inner secretions )it co%g ing(
Administer medications (e7g7, antibiotics, mucolytic agents, bronc#odilators, e!pectorants) as ordered, noting effectiveness and side effects7 For patients ,it# c#ronic problems ,it# bronc#oconstriction, instruct in use of metered+ dose in#aler (2D%) or nebuli1er as prescribed7 Consult respiratory t#erapist for c#est p#ysiot#erapy and nebuli1er treatments as indicated (#ospital and #ome care/re#abilitation environments)7 C est $ ysiot era$y incl%des t e tec ni*%es of $ost%ral drainage and c est $erc%ssion to &obili7e secretions in s&aller air)ays t at cannot be re&o+ed by co%g ing or s%ctioning( Coordinate optimal time for postural drainage and percussion (i7e7, at least 9 #our after eating)7 T is $re+ents as$iration(
For patients ,it# reduced energy, pace activities7 2aintain planned rest periods7 *romote energy+conservation tec#ni/ues7 !atig%e is a contrib%ting factor to ineffecti+e co%g ing( For acute problem, assist ,it# bronc#oscopy7 T is obtains la+age sa&$les for c%lt%re and sensiti+ity' and re&o+es &%c%s $l%gs( 9E
%f secretions cannot be cleared, anticipate t#e need for an artificial air,ay (intubation)7 After intubation

%nstitute suctioning of air,ay as determined by presence of adventitious sounds7 -se sterile saline instillations during suctioning7 T is el$s facilitate re&o+al of tenacio%s s$%t%&(
For patients ,it# complete air,ay obstruction, institute cardiopulmonary resuscitation (C*R) maneuvers7
Demonstrate and teac# coug#ing, deep breat#ing, and splinting tec#ni/ues7 4atient )ill %nderstand t e rationale and a$$ro$riate tec ni*%es to kee$ t e air)ay clear of secretions(
%nstruct patient on indications for, fre/uency, and side effects of medications7 %nstruct patient #o, to use prescribed in#alers, as appropriate7 %n #ome setting, instruct caregivers regarding coug# en#ancement tec#ni/ues and need for #umidification7 %nstruct caregivers in suctioning tec#ni/ues7 *rovide opportunity for return demonstration7 Adapt tec#ni/ue for #ome setting7 For patients ,it# debilitating disease being cared for at #ome (C3A, neuromuscular impairment, and ot#ers), instruct caregiver in c#est p#ysiot#erapy as appropriate7 T is &ay also be %sef%l for t e $atient )it bronc iectasis ) o is a&b%latory b%t re*%ires c est $ ysiot era$y beca%se of t e +ol%&e of secretions and t e inability to ade*%ately clear t e&(
"eac# patient about environmental factors t#at can precipitate respiratory problems7 $!plain effects of smoking, including second+#and smoke7 S&oking contrib%tes to bronc os$as& and increased &%c%s $rod%ction in t e air)ays( Refer patient and/or significant ot#ers to smoking+cessation group, as appropriate, and discuss potential use of smoking+cessation aids (e7g7, .icorette (um, .icoderm, or )abitrol) to ,ean off t#e effects of nicotine7
%nstruct patient on ,arning signs of pending or recurring pulmonary problems7
9F
Refer to pulmonary clinical nurse specialist, #ome #ealt# nurse, or respiratory t#erapist as indicated7
;:
Risk for As$iration

NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Risk Control Risk Detection Respiratory Status 3entilation
Aspiration *recautions
NANDA Definition: At risk for entry of gastrointestinal secretions, orop#aryngeal secretions, or solids or fluids into trac#eobronc#ial passages 'ot# acute and c#ronic conditions can place patients at risk for aspiration7 Acute conditions, suc# as postanest#esia effects from surgery or diagnostic tests, occur predominantly in t#e acute care setting7 C#ronic conditions, including altered consciousness from #ead in&ury, spinal cord in&ury, neuromuscular ,eakness, #emiplegia and dysp#agia from stroke, use of tube feedings for nutrition, endotrac#eal intubation, or mec#anical ventilation may be encountered in t#e #ome, re#abilitative, or #ospital settings7 $lderly and cognitively impaired patients are at #ig# risk7 Aspiration is a common cause of deat# in comatose patients7 Risk !actors: Reduced level of consciousness, Depressed coug# and gag refle!es, *resence of trac#eostomy or endotrac#eal tube, *resence of gastrointestinal tubes, "ube feedings, Anest#esia or medication administration, Decreased gastrointestinal motility, %mpaired s,allo,ing, Facial, oral, or neck surgery or trauma, Situations #indering elevation of upper body "#$ected O%tco&es : *atient maintains patent air,ay7 *atientBs risk of aspiration is decreased as a result of ongoing assessment and early intervention7
;9
Ongoing Assess&ent
2onitor level of consciousness7 A decreased le+el of conscio%sness is a $ri&e risk factor for as$iration(
Assess coug# and gag refle!es7 A de$ressed co%g or gag refle# increases t e risk of as$iration(
2onitor s,allo,ing ability

Assess for coug#ing or clearing of t#e t#roat after a s,allo,7 Assess for residual food in mout# after eating7 4ockets of food can be easily as$irated at a later ti&e( Assess for regurgitation of food or fluid t#roug# nares7 2onitor for c#oking during eating or drinking7 C oking indicates as$iration( Auscultate bo,el sounds to evaluate bo,el motility7 Decreased gastrointestinal &otility increases t e risk of as$iration beca%se food or fl%ids acc%&%late in t e sto&ac ( "lderly $atients a+e a decrease in eso$ ageal &otility' ) ic delays eso$ ageal e&$tying( W en co&bined )it t e )eaker gag refle# of elderly $atients' as$iration is a ig er risk(
Assess for presence of nausea or vomiting7 Assess pulmonary status for clinical evidence of aspiration7 Auscultate breat# sounds for development of crackles and/or r#onc#i7 As$iration of s&all a&o%nts can occ%r )it o%t co%g ing or s%dden onset of res$iratory distress' es$ecially in $atients )it decreased le+els of conscio%sness(
%n patients ,it# endotrac#eal or trac#eostomy tubes, monitor t#e effectiveness of t#e cuff7 Collaborate ,it# t#e respiratory t#erapist, as needed, to determine cuff pressure7 An ineffecti+e c%ff can increase t e risk of as$iration(
6eep suction setup available (in bot# #ospital and #ome settings) and use as needed7 T is is necessary to &aintain a $atent air)ay(
;;
.otify t#e p#ysician or ot#er #ealt# care provider immediately of noted decrease in coug# and/or gag refle!es or difficulty in s,allo,ing7 "arly inter+ention $rotects t e $atient<s air)ay and $re+ents as$iration(
*osition patients ,#o #ave a decreased level of consciousness on t#eir sides7 T is $rotects t e air)ay( 4ro$er $ositioning can decrease t e risk of as$iration( Co&atose $atients need fre*%ent t%rning to facilitate drainage of secretions(
Supervise or assist patient ,it# oral intake7 .ever give oral fluids to a comatose patient7 T is )ill el$ detect abnor&alities early( 0ffer foods ,it# consistency t#at patient can s,allo,7 -se t#ickening agents as appropriate7 Cut foods into small pieces7 Se&isolid foods like $%dding and ot cereal are &ost easily s)allo)ed( 8i*%ids and t in foods like crea&ed so%$s are &ost diffic%lt for $atients )it dys$ agia(
$ncourage patient to c#e, t#oroug#ly and eat slo,ly during meals7 %nstruct patient not to talk ,#ile eating7 For patients ,it# reduced cognitive abilities, remove distracting stimuli during mealtimes7 T is facilitates concentration on c e)ing and s)allo)ing( *lace ,#ole or crus#ed pills in soft foods (e7g7, custard)7 3erify ,it# a p#armacist ,#ic# pills s#ould not be crus#ed7 Substitute medication in eli!ir form as indicated7 *osition patient at F:+degree angle, ,#et#er in bed or in a c#air or ,#eelc#air7 -se cus#ions or pillo,s to maintain position7 4ro$er $ositioning of $atients )it s)allo)ing diffic%lties is of $ri&ary i&$ortance d%ring feeding or eating(
2aintain uprig#t position for >: to ?= minutes after feeding7 T e %$rig t $osition facilitates t e gra+itational flo) of food or fl%id t ro%g t e ali&entary tract( If t e ead of t e bed cannot be ele+ated beca%se of t e $atient<s condition' %se a rig t side: lying $osition after feedings to facilitate $assage of sto&ac contents into t e d%oden%&(
*rovide oral care after meals7 T is re&o+es resid%als and red%ces $ocketing of food t at can be later as$irated( %n patients ,it# nasogastric (.() or gastrostomy tubes C#eck placement before feeding7 A dis$laced t%be &ay erroneo%sly deli+er t%be feeding into t e air)ay(
;>
C#eck residuals before feeding7 )old feedings if residuals are #ig# and notify t#e p#ysician7 /ig a&o%nts of resid%al -=>1? of $re+io%s o%r<s intake. indicate delayed gastric e&$tying and can ca%se distention of t e sto&ac leading to refl%# e&esis(
*lace dye (e7g7, met#ylene blue) in .( feedings7 Detection of t e color in $%l&onary secretions )o%ld indicate as$iration(
*osition ,it# #ead of bed elevated >: to ?= degrees7
-se speec# pat#ology consultation as appropriate7 A s$eec $at ologist can be cons%lted to $erfor& a dys$ agia assess&ent t at el$s deter&ine t e need for +ideofl%orosco$y or &odified bari%& s)allo)(
$!plain to patient/caregiver t#e need for proper positioning7 T is decreases t e risk of as$iration( %nstruct on proper feeding tec#ni/ues7 %nstruct on upper+air,ay suctioning tec#ni/ues to prevent accumulation of secretions in t#e oral cavity7 %nstruct on signs and symptoms of aspiration7 T is aids in a$$ro$riately assessing ig : risk sit%ations and deter&ining ) en to call for f%rt er e+al%ation( %nstruct caregiver on ,#at to do in t#e event of an emergency7 Refer to #ome #ealt# nurse, re#abilitation specialist, or occupational t#erapist as indicated7
An#iety

An!iety Reduction *resence Calming "ec#ni/ue $motional Support
;?
NANDA Definition: 3ague uneasy feeling of discomfort or dread accompanied by an autonomic response (t#e source often nonspecific or unkno,n to t#e individual)< a feeling of appre#ension caused by anticipation of danger7 %t is an alerting signal t#at ,arns of impending danger and enables t#e individual to take measures to deal ,it# t#e t#reat7 An!iety is probably present at some level in every individualBs life, but t#e degree and t#e fre/uency ,it# ,#ic# it manifests differs broadly7 $ac# individualBs response to an!iety is different7 Some people are able to use t#e emotional edge t#at an!iety provokes to stimulate creativity or problem+solving abilities< ot#ers can become immobili1ed to a pat#ological degree7 "#e feeling is generally categori1ed into four levels for treatment purposes mild, moderate, severe, and panic7 "#e nurse can encounter t#e an!ious patient any,#ere in t#e #ospital or community7 "#e presence of t#e nurse may lend support to t#e an!ious patient and provide some strategies for traversing an!ious moments or panic attacks7 Defining C aracteristics: *#ysiological %ncrease in blood pressure, pulse, and respirations, Di11iness, lig#t+#eadedness, *erspiration, Fre/uent urination, Flus#ing, Dyspnea, *alpitations, Dry mout#, )eadac#es, .ausea and/or diarr#ea, Restlessness, *acing, *upil dilation, %nsomnia, nig#tmares, "rembling, Feelings of #elplessness and discomfort @e a+ioral: $!pressions of #elplessness, Feelings of inade/uacy, Crying, Difficulty concentrating, Rumination, %nability to problem+solve, *reoccupation Related !actors "#reat or perceived t#reat to p#ysical and emotional integrity, C#anges in role function, %ntrusive diagnostic and surgical tests and procedures, C#anges in environment and routines, "#reat or perceived t#reat to self+concept, "#reat to (or c#ange in) socioeconomic status, Situational and maturational crises, %nterpersonal conflicts7 "#$ected O%tco&es: *atient is able to recogni1e signs of an!iety7 *atient demonstrates positive coping mec#anisms7 *atient may describe a reduction in t#e level of an!iety e!perienced7 Ongoing Assess&ent
Assess patientBs level of an!iety7 6ild an#iety en ances t e $atient<s a)areness and ability to identify and sol+e $roble&s( 6oderate an#iety li&its a)areness of ;=
en+iron&ental sti&%li( 4roble& sol+ing can occ%r b%t &ay be &ore diffic%lt' and $atient &ay need el$( Se+ere an#iety decreases $atient<s ability to integrate infor&ation and sol+e $roble&s( Wit $anic t e $atient is %nable to follo) directions( /y$eracti+ity' agitation' and i&&obili7ation &ay be obser+ed(
Determine #o, patient copes ,it# an!iety7 T is can be done by inter+ie)ing t e $atient( T is assess&ent el$s deter&ine t e effecti+eness of co$ing strategies c%rrently %sed by $atient(
Suggest t#at t#e patient keep a log of episodes of an!iety7 %nstruct patient to describe ,#at is e!perienced and t#e events leading up to and surrounding t#e event7 *atient s#ould note #o, t#e an!iety dissipates7 4atient &ay %se t ese notes to begin to identify trends t at &anifest an#iety( If t e $atient is co&fortable )it t e idea' t e log &ay be s ared )it t e care $ro+ider ) o &ay be el$f%l in $roble& sol+ing( Sy&$to&s often $ro+ide t e care $ro+ider )it infor&ation regarding t e degree of an#iety being e#$erienced( 4 ysiological sy&$to&s and3or co&$laints intensify as t e le+el of an#iety increases(
Ackno,ledge a,areness of patientBs an!iety7 @eca%se a ca%se for an#iety cannot al)ays be identified' t e $atient &ay feel as t o%g t e feelings being e#$erienced are co%nterfeit( Ackno)ledg&ent of t e $atient<s feelings +alidates t e feelings and co&&%nicates acce$tance of t ose feelings(
Reassure patient t#at #e or s#e is safe7 Stay ,it# patient if t#is appears necessary7 T e $resence of a tr%sted $erson &ay be el$f%l d%ring an an#iety attack( 2aintain a calm manner ,#ile interacting ,it# patient7 T e ealt care $ro+ider can trans&it is or er o)n an#iety to t e y$ersensiti+e $atient( T e $atient<s feeling of stability increases in a cal& and nont reatening at&os$ ere(
$stablis# a ,orking relations#ip ,it# t#e patient t#roug# continuity of care7 An ongoing relations i$ establis es a basis for co&fort in co&&%nicating an#io%s feelings( 0rient patient to t#e environment and ne, e!periences or people as needed7 Orientation and a)areness of t e s%rro%ndings $ro&ote co&fort and &ay decrease an#iety(
;C
-se simple language and brief statements ,#en instructing patient about self+care measures or about diagnostic and surgical procedures7 W en e#$eriencing &oderate to se+ere an#iety' $atients &ay be %nable to co&$re end anyt ing &ore t an si&$le' clear' and brief instr%ctions(
Reduce sensory stimuli by maintaining a /uiet environment< keep Gt#reateningG e/uipment out of sig#t7 An#iety &ay escalate )it e#cessi+e con+ersation' noise' and e*%i$&ent aro%nd t e $atient( T is &ay be e+ident in bot os$ital and o&e en+iron&ents(
$ncourage patient to seek assistance from an understanding significant ot#er or from t#e #ealt# care provider ,#en an!ious feelings become difficult7 T e $resence of significant ot ers reinforces feelings of sec%rity for t e $atient(
$ncourage patient to talk about an!ious feelings and e!amine an!iety+provoking situations if able to identify t#em7 Assist patient in assessing t#e situation realistically and recogni1ing factors leading to t#e an!ious feelings7 Avoid false reassurances7
As patientBs an!iety subsides, encourage e!ploration of specific events preceding bot# t#e onset and reduction of t#e an!ious feelings7 Recognition and e#$loration of factors leading to or red%cing an#io%s feelings are i&$ortant ste$s in de+elo$ing alternati+e res$onses( 4atient &ay be %na)are of t e relations i$ bet)een e&otional concerns and an#iety(
Assist t#e patient in developing an!iety+reducing skills (e7g7, rela!ation, deep breat#ing, positive visuali1ation, and reassuring self+statements)7 Using an#iety:red%ction strategies en ances $atient<s sense of $ersonal &astery and confidence(
Assist patient in developing problem+solving abilities7 $mp#asi1e t#e logical strategies patient can use ,#en e!periencing an!ious feelings7 8earning to identify a $roble& and e+al%ate alternati+es to resol+e it el$s t e $atient to co$e(
%nstruct t#e patient in t#e appropriate use of antian!iety medications7
Assist patient in recogni1ing symptoms of increasing an!iety< e!plore alternatives to use to prevent t#e an!iety from immobili1ing #er or #im7 T e ability to recogni7e an#iety sy&$to&s at lo)er:intensity le+els enables t e $atient to inter+ene &ore *%ickly to
;D
&anage is or er an#iety( 4atient )ill be able to %se $roble&:sol+ing abilities &ore effecti+ely ) en t e le+el of an#iety is lo)(
Remind patient t#at an!iety at a mild level can encourage gro,t# and development and is important in mobili1ing c#anges7 %nstruct patient in t#e proper use of medications and educate #im or #er to recogni1e adverse reactions7 6edication &ay be %sed if $atient<s an#iety contin%es to escalate and t e an#iety beco&es disabling(
Refer t#e patient for psyc#iatric management of an!iety t#at becomes disabling for an e!tended period7
Decreased Cardiac O%t$%t


Cardiac *ump $ffectiveness Circulation Status 6no,ledge Disease *rocess 6no,ledge "reatment *rogram

Cardiac Care )emodynamic Regulation "eac#ing Disease *rocess
NANDA Definition: %nade/uate blood pumped by t#e #eart to meet t#e metabolic demands of t#e body Common causes of reduced cardiac output include myocardial infarction, #ypertension, valvular #eart disease, congenital #eart disease, cardiomyopat#y, pulmonary disease, arr#yt#mias, drug
;E
effects, fluid overload, decreased fluid volume, and electrolyte imbalance7 (eriatric patients are especially at risk because t#e aging process causes reduced compliance of t#e ventricles, ,#ic# furt#er reduces contractility and cardiac output7 *atients may #ave acute, temporary problems or e!perience c#ronic, debilitating effects of decreased cardiac output7 *atients may be managed in an acute, ambulatory care, or #ome care setting7 "#is care plan focuses on t#e acute management7 Defining C aracteristics: 3ariations in #emodynamic parameters (blood pressure @'*A, #eart rate, central venous pressure @C3*A, pulmonary artery pressures, venous o!ygen saturation @S30;A, cardiac output), Arr#yt#mias, electrocardiogram ($C() c#anges, Rales, tac#ypnea, dyspnea, ort#opnea, coug#, abnormal arterial blood gases (A'(s), frot#y sputum, 4eig#t gain, edema, decreased urine output, An!iety, restlessness, Syncope, di11iness, 4eakness, fatigue, Abnormal #eart sounds, Decreased perip#eral pulses, cold clammy skin, Confusion, c#ange in mental status, Angina, $&ection fraction less t#an ?:H, *ulsus alternans7 Related !actors: %ncreased or decreased ventricular filling (preload), Alteration in afterload, %mpaired contractility, Alteration in #eart rate, r#yt#m, and conduction, Decreased o!ygenation, Cardiac muscle disease "#$ected O%tco&es *atient maintains '* ,it#in normal limits< ,arm, dry skin< regular cardiac r#yt#m< clear lung sounds< and strong bilateral, e/ual perip#eral pulses7 Ongoing Assess&ent
Assess mentation7 Restlessness is noted in t e early stages; se+ere an#iety and conf%sion are seen in later stages( Assess #eart rate and blood pressure7 Sin%s tac ycardia and increased arterial blood $ress%re are seen in t e early stages; @4 dro$s as t e condition deteriorates( "lderly $atients a+e red%ced res$onse to catec ola&ines' t %s t eir res$onse to red%ced cardiac o%t$%t &ay be bl%nted' )it less rise in eart rate( 4%ls%s alternans -alternating strong:t en:)eak $%lse. is often seen in eart fail%re $atients(
;F
Assess skin color and temperature7 Cold' cla&&y skin is secondary to co&$ensatory increase in sy&$at etic ner+o%s syste& sti&%lation and lo) cardiac o%t$%t and desat%ration(
Assess perip#eral pulses7 4%lses are )eak )it red%ced cardiac o%t$%t( Assess fluid balance and ,eig#t gain7 Co&$ro&ised reg%latory &ec anis&s &ay res%lt in fl%id and sodi%& retention( @ody )eig t is a &ore sensiti+e indicator of fl%id or sodi%& retention t an intake and o%t$%t(
Assess #eart sounds, noting gallops, S>, S?7 S2 denotes red%ced left +entric%lar e,ection and is a classic sign of left +entric%lar fail%re( SA occ%rs )it red%ced co&$liance of t e left +entricle' ) ic i&$airs diastolic filling(
Assess lung sounds7 Determine any occurrence of paro!ysmal nocturnal dyspnea (*.D) or ort#opnea7 Crackles reflect acc%&%lation of fl%id secondary to i&$aired left +entric%lar e&$tying( T ey are &ore e+ident in t e de$endent areas of t e l%ng( Ort o$nea is diffic%lty breat ing ) en s%$ine( 4ND is diffic%lty breat ing t at occ%rs at nig t(
%f #emodynamic monitoring is in place 2onitor central venous, rig#t arterial pressure @RA*A, pulmonary artery pressure (*A*) (systolic, diastolic, and mean), and pulmonary capillary ,edge pressure (*C4*)7 /e&odyna&ic $ara&eters $ro+ide infor&ation aiding in differentiation of decreased cardiac o%t$%t secondary to fl%id o+erload +ers%s fl%id deficit(
2onitor S30 ; continuously7 C ange in o#ygen sat%ration of &i#ed +eno%s blood is one of t e earliest indicators of red%ced cardiac o%t$%t( *erform cardiac output determination7 T is $ro+ides ob,ecti+e n%&ber to g%ide t era$y( 2onitor continuous $C( as appropriate7 2onitor $C( for rate< r#yt#m< ectopy< and c#ange in *R, IRS, and I" intervals7 Tac ycardia' bradycardia' and ecto$ic beats can co&$ro&ise cardiac o%t$%t( "lderly $atients are es$ecially sensiti+e to t e loss of atrial kick in atrial fibrillation(
Assess response to increased activity7 4 ysical acti+ity increases t e de&ands $laced on t e eart; fatig%e and e#ertional dys$nea are co&&on $roble&s )it lo) cardiac o%t$%t states( Close &onitoring of $atient<s res$onse ser+es as a g%ide for o$ti&al $rogression of acti+ity(
>:
Assess urine output7 Determine #o, often t#e patient urinates7 Olig%ria can reflect decreased renal $erf%sion( Di%resis is e#$ected )it di%retic t era$y( Assess for c#est pain7 T is indicates an i&balance bet)een o#ygen s%$$ly and de&and( Assess contributing factors so appropriate plan of care can be initiated7
Administer medication as prescribed, noting response and ,atc#ing for side effects and to!icity7 Clarify ,it# p#ysician parameters for ,it##olding medications7 De$ending on etiological factors' co&&on &edications incl%de digitalis t era$y' di%retics' +asodilator t era$y' antidysr yt &ics' AC" in ibitors' and inotro$ic agents( 2aintain optimal fluid balance7 For patients ,it# decreased preload, administer fluid c#allenge as prescribed, closely monitoring effects7 Ad&inistration of fl%id increases e#tracell%lar fl%id +ol%&e to raise cardiac o%t$%t( 2aintain #emodynamic parameters at prescribed levels7 !or $atients in t e ac%te setting' close &onitoring of t ese $ara&eters g%ides titration of fl%ids and &edications( For patients ,it# increased preload, restrict fluids and sodium as ordered7 T is decreases e#tracell%lar fl%id +ol%&e( 2aintain ade/uate ventilation and perfusion, as in t#e follo,ing
*lace patient in semi+ to #ig#+Fo,lerBs position7 T is red%ces $reload and +entric%lar filling( *lace in supine position7 T is increases +eno%s ret%rn' $ro&otes di%resis( Administer #umidified o!ygen as ordered7 T e failing eart &ay not be able to res$ond to increased o#ygen de&ands(
2aintain p#ysical and emotional rest, as in t#e follo,ing

Restrict activity7 T is red%ces o#ygen de&ands( *rovide /uiet, rela!ed environment7 "&otional stress increases cardiac de&ands( 0rgani1e nursing and medical care7 T is allo)s rest $eriods( 2onitor progressive activity ,it#in limits of cardiac function7
Administer stool softeners as needed7 Straining for a bo)el &o+e&ent f%rt er i&$airs cardiac o%t$%t( 2onitor sleep patterns< administer sedative7 Rest is i&$ortant for conser+ing energy( >9
%f arr#yt#mia occurs, determine patient response, document, and report if significant or symptomatic7

)ave antiarr#yt#mic drugs readily available7 "reat arr#yt#mias according to medical orders or protocol and evaluate response7
@ot tac yarr yt &ias and bradyarr yt &ias can red%ce cardiac o%t$%t and &yocardial tiss%e $erf%sion(
%f invasive ad&unct t#erapies are indicated (e7g7, intraaortic balloon pump, pacemaker), maintain ,it#in prescribed protocol7
$!plain symptoms and interventions for decreased cardiac output related to etiological factors7 $!plain drug regimen, purpose, dose, and side effects7 $!plain progressive activity sc#edule and signs of overe!ertion7 $!plain diet restrictions (fluid, sodium)7
Ineffecti+e @reat ing 4attern

NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels >;
Respiratory Status 3entilation
3ital Sign Status

Air,ay 2anagement Respiratory 2onitoring
NANDA Definition: %nspiration and/or e!piration t#at does not provide ade/uate ventilation Respiratory pattern monitoring addresses t#e patientBs ventilatory pattern, rate, and dept#7 2ost acute pulmonary deterioration is preceded by a c#ange in breat#ing pattern7 Respiratory failure can be seen ,it# a c#ange in respiratory rate, c#ange in normal abdominal and t#oracic patterns for inspiration and e!piration, c#ange in dept# of ventilation (3t), and respiratory alternans7 'reat#ing pattern c#anges may occur in a multitude of cases from #ypo!ia, #eart failure, diap#ragmatic paralysis, air,ay obstruction, infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and an!iety, metabolic abnormalities (e7g7, diabetic ketoacidosis @D6AA, uremia, or t#yroid dysfunction), peritonitis, drug overdose, and pleural inflammation7 Defining C aracteristics: Dyspnea, "ac#ypnea, Fremitus, Cyanosis, Coug#, .asal flaring, Respiratory dept# c#anges, Altered c#est e!cursion, -se of accessory muscles, *ursed+lip breat#ing or prolonged e!piratory p#ase, %ncreased anteroposterior c#est diameter Related !actors: %nflammatory process viral or bacterial, )ypo!ia, .euromuscular impairment, *ain, 2usculoskeletal impairment, "rac#eobronc#ial obstruction, *erception or cognitive impairment, An!iety, Decreased energy and fatigue, Decreased lung e!pansion "#$ected O%tco&es: *atientBs breat#ing pattern is maintained as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern7
>>
Ongoing Assess&ent
Assess respiratory rate and dept# by listening to lung sounds7 Res$iratory rate and r yt & c anges are early )arning signs of i&$ending res$iratory diffic%lties( Assess for dyspnea and /uantify (e7g7, note #o, many ,ords per breat# patient can say)< relate dyspnea to precipitating factors7
Assess for dyspnea at rest versus activity and note c#anges7 Dys$nea t at occ%rs )it acti+ity &ay indicate acti+ity intolerance(
2onitor breat#ing patterns

'radypnea (slo, respirations) "ac#ypnea (increase in respiratory rate) )yperventilation (increase in respiratory rate or tidal volume, or bot#) 6ussmaulBs respirations (deep respirations ,it# fast, normal, or slo, rate) C#eyne+Stokes respiration (,a!ing and ,aning ,it# periods of apnea bet,een a repetitive pattern) Apneusis (sustained ma!imal in#alation ,it# pause) 'iotBs respiration (irregular periods of apnea alternating ,it# periods in ,#ic# four or five breat#s of identical dept# are taken) Ata!ic patterns (irregular and unpredictable pattern ,it# periods of apnea)
S$ecific breat ing $atterns &ay indicate an %nderlying disease $rocess or dysf%nction( C eyne:Stokes res$iration re$resents bilateral dysf%nction in t e dee$ cerebral or dience$ alon associated )it brain in,%ry or &etabolic abnor&alities( A$ne%sis and ata#ic breat ing are associated )it fail%re of t e res$iratory centers in t e $ons and &ed%lla(
.ote muscles used for breat#ing (e7g7, sternocleido+mastoid, abdominal, diap#ragmatic)7 T e accessory &%scles of ins$iration are not %s%ally in+ol+ed in *%iet breat ing( T ese incl%de t e scalenes -attac to t e first t)o ribs. and t e sternocleido&astoid -ele+ates t e stern%&.(
2onitor for diap#ragmatic muscle fatigue (parado!ical motion)7 4arado#ical &o+e&ent of t e dia$ rag& indicates a re+ersal of t e nor&al $attern and is indicati+e of
>?
+entilatory &%scle fatig%e and3or res$iratory fail%re( T e dia$ rag& is t e &ost i&$ortant &%scle of +entilation' nor&ally res$onsible for B1? to B>? of +entilation d%ring restf%l breat ing(

.ote retractions or flaring of nostrils7 T ese signify an increase in )ork of breat ing( Assess position patient assumes for normal or easy breat#ing7 -se pulse o!imetry to monitor o!ygen saturation and pulse rate7 4%lse o#i&etry is a %sef%l tool to detect c anges in o#ygenation early on; o)e+er' for CO0 le+els' end tidal CO0 &onitoring or arterial blood gases -A@Gs. )o%ld need to be obtained(
2onitor A'(s as appropriate< note c#anges7 Increasing 4aCO0 and decreasing 4aO0 are signs of res$iratory fail%re( As t e $atient begins to fail' t e res$iratory rate decreases and 4aCO0 begins to rise(
2onitor for c#anges in orientation, increased restlessness, an!iety, and air #unger7 Restlessness is an early sign of y$o#ia( Avoid #ig# concentration of o!ygen in patients ,it# c#ronic obstructive pulmonary disease (C0*D)7 /y$o#ia sti&%lates t e dri+e to breat e in t e c ronic CO0 retainer $atient( W en a$$lying o#ygen' close &onitoring is i&$erati+e to $re+ent %nsafe increases in t e $atient<s 4aO0 ' ) ic co%ld res%lt in a$nea(
Assess skin color, temperature, capillary refill< note central versus perip#eral cyanosis7 2onitor vital capacity in patients ,it# neuromuscular ,eakness and observe trends7 6onitoring detects c anges early( Assess presence of sputum for /uantity, color, consistency7 %f t#e sputum is discolored (no longer clear or ,#ite), send sputum specimen for culture and sensitivity, as appropriate7 An infection &ay be $resent( Res$iratory infections increase t e )ork of breat ing; antibiotic treat&ent &ay be indicated(
Assess ability to clear secretions7 T e inability to clear secretions &ay add to a c ange in breat ing $attern( Assess for pain7 4osto$erati+e $ain can res%lt in s allo) breat ing(
*osition patient ,it# proper body alignment for optimal breat#ing pattern7 If not contraindicated' a sitting $osition allo)s for good l%ng e#c%rsion and c est e#$ansion( >=
$nsure t#at o!ygen delivery system is applied to t#e patient7 T e a$$ro$riate a&o%nt of o#ygen is contin%o%sly deli+ered so t at t e $atient does not desat%rate( An o!ygen saturation of F:H or greater s#ould be maintained7 T is $ro+ides for ade*%ate o#ygenation(
$ncourage sustained deep breat#s by
-sing demonstration (emp#asi1ing slo, in#alation, #olding end inspiration for a fe, seconds, and passive e!#alation) -sing incentive spirometer (place close for convenient patient use) Asking patient to ya,n T is si&$le tec ni*%e $ro&otes dee$ ins$iration(
$valuate appropriateness of inspiratory muscle training7 T is i&$ro+es conscio%s control of res$iratory &%scles( 2aintain a clear air,ay by encouraging patient to clear o,n secretions ,it# effective coug#ing7 %f secretions cannot be cleared, suction as needed to clear secretions7 -se universal precautions (e7g7, gloves, goggles, and mask) as appropriate7 %f secretions are purulent, precautions s#ould be instituted before receiving t#e culture and sensitivity final report7 %nstitute appropriate isolation procedures for positive cultures (e7g7, met#icillin+ resistant Stap#ylococcus aureus, tuberculosis @"'A)7
*ace and sc#edule activities providing ade/uate rest periods7 T is $re+ents dys$nea res%lting fro& fatig%e( *rovide reassurance and allay an!iety by staying ,it# patient during acute episodes of respiratory distress7 Air %nger can $rod%ce an e#tre&ely an#io%s state( *rovide rela!ation training as appropriate (e7g7, biofeedback, imagery, progressive muscle rela!ation)7 $ncourage diap#ragmatic breat#ing for patient ,it# c#ronic disease7 -se pain management as appropriate7 T is allo)s for $ain relief and t e ability to dee$ breat e( Anticipate t#e need for intubation and mec#anical ventilation if patient is unable to maintain ade/uate gas e!c#ange ,it# t#e present breat#ing pattern7
>C

$!plain all procedures before performing7 T is decreases $atient<s an#iety( $!plain effects of ,earing restrictive clot#ing7 Res$iratory e#c%rsion is not co&$ro&ised( $!plain use of o!ygen t#erapy, including t#e type and use of e/uipment and ,#y its maintenance is important7 ratioIss%es related to o&e o#ygen %se' storage' and $reca%tions need to be addressed(
%nstruct about medications indications, dosage, fre/uency, and potential side effects7 %nclude revie, of metered+dose in#aler and nebuli1er treatments, as appropriate7 Revie, t#e use of at+#ome monitoring capabilities and refer to #ome #ealt# nursing, o!ygen vendors, and ot#er resources for rental e/uipment as appropriate7 $!plain environmental factors t#at may ,orsen patientBs pulmonary condition (e7g7, pollen, second+#and smoke) and discuss possible precipitating factors (e7g7, allergens and emotional stress)7
$!plain symptoms of a GcoldG and impending problems7 A res$iratory infection )o%ld increase t e )ork of breat ing( "eac# patient or caregivers appropriate breat#ing, coug#ing, and splinting tec#ni/ues7 T ese facilitate ade*%ate clearance of secretions( "eac# patient #o, to count o,n respirations and relate respiratory rate to activity tolerance7 4atient )ill t en kno) ) en to li&it acti+ities in ter&s of is or er o)n li&itations( "eac# patient ,#en to in#ale and e!#ale ,#ile doing strenuous activities7 A$$ro$riate breat ing tec ni*%es d%ring e#ercise are i&$ortant in &aintaining ade*%ate gas e#c ange(
Assist patient or caregiver in learning signs of respiratory compromise7 Refer significant ot#er/caregiver to participate in basic life support class for C*R, as appropriate7 Refer to social services for furt#er counseling related to patientBs condition and give list of support groups or a contact person from t#e support group for t#e patient to talk ,it#7
Dist%rbed @ody I&age
>D

'ody %mage Self+$steem

'ody %mage $n#ancement (rief 4ork Facilitation Coping $n#ancement
NANDA Definition: Confusion in mental picture of oneBs p#ysical self 'ody image is t#e attitude a person #as about t#e actual or perceived structure or function of all or part of #is or #er body7 "#is attitude is dynamic and is altered t#roug# interaction ,it# ot#er persons and situations and influenced by age and developmental level7 As an important part of oneBs self+concept, body image disturbance can #ave profound impact on #o, individuals vie, t#eir overall selves7 "#roug#out t#e life span, body image c#anges as a matter of development, gro,t#, maturation, c#anges related to c#ildbearing and pregnancy, c#anges t#at occur as a result of aging, and c#anges t#at occur or are imposed as a result of in&ury or illness7 %n cultures ,#ere oneBs appearance is important, variations from t#e norm can result in body image disturbance7 "#e importance t#at an individual places on a body part or function may be more important in determining t#e degree of disturbance t#an t#e actual alteration in t#e structure or function7 "#erefore t#e loss of a limb may result in a greater body image disturbance for an at#lete t#an for a computer programmer7 "#e loss of a breast to a fas#ion model or a #ysterectomy in a nulliparous ,oman may cause serious body image disturbances even t#oug# t#e overall #ealt# of t#e individual #as been improved7 Removal of skin lesions, altered elimination resulting from
>E
bo,el or bladder surgery, and #ead and neck resections are ot#er e!amples t#at can lead to body image disturbance7 "#e nurseBs assessment of t#e perceived alteration and importance placed by t#e patient on t#e altered structure or function ,ill be very important in planning care to address body image disturbance7 Defining C aracteristics: 3erbali1ation about altered structure or function of a body part, 3erbal preoccupation ,it# c#anged body part or function, .aming c#anged body part or function, Refusal to discuss or ackno,ledge c#ange, Focusing be#avior on c#anged body part and/or function, Actual c#ange in structure or function, Refusal to look at, touc#, or care for altered body part, C#ange in social be#avior (e7g7, ,it#dra,al, isolation, flamboyance), Compensatory use of concealing clot#ing or ot#er devices Related !actors: Situational c#anges (e7g7, pregnancy, temporary presence of a visible drain or tube, dressing, attac#ed e/uipment), *ermanent alterations in structure and/or function (e7g7, mutilating surgery, removal of body part @internal or e!ternalA), 2alodorous lesions, C#ange in voice /uality7 "#$ected O%tco&es *atient demonstrates en#anced body image and self+esteem as evidenced by ability to look at, touc#, talk about, and care for actual or perceived altered body part or function7 Ongoing Assess&ent
Assess perception of c#ange in structure or function of body part (also proposed c#ange)7 T e e#tent of t e res$onse is &ore related to t e +al%e or i&$ortance t e $atient $laces on t e $art or f%nction t an t e act%al +al%e or i&$ortance( "+en ) en an alteration i&$ro+es t e o+erall ealt of t e indi+id%al -e(g(' an ileosto&y for an indi+id%al )it $recancero%s colon $oly$s.' t e alteration res%lts in a body i&age dist%rbance(
Assess perceived impact of c#ange on activities of daily living (AD5s), social be#avior, personal relations#ips, and occupational activities7
>F
Assess impact of body image disturbance in relation to patientBs developmental stage7 Adolescents and yo%ng ad%lts &ay be $artic%larly affected by c anges in t e str%ct%re or f%nction of t eir bodies at a ti&e ) en de+elo$&ental c anges are nor&ally ra$id' and at a ti&e ) en de+elo$ing social and inti&ate relations i$s is $artic%larly i&$ortant(
.ote patientBs be#avior regarding actual or perceived c#anged body part or function7 T ere is a broad range of be a+iors associated )it body i&age dist%rbance' ranging fro& totally ignoring t e altered str%ct%re or f%nction to $reocc%$ation )it it(
.ote fre/uency of self+critical remarks7
Ackno,ledge normalcy of emotional response to actual or perceived c#ange in body structure or function7 Stages of grief o+er loss of a body $art or f%nction is nor&al' and ty$ically in+ol+es a $eriod of denial' t e lengt of ) ic +aries fro& indi+id%al to indi+id%al(
)elp patient identify actual c#anges7 4atients &ay $ercei+e c anges t at are not $resent or real' or t ey &ay be $lacing %nrealistic +al%e on a body str%ct%re or f%nction( $ncourage verbali1ation of positive or negative feelings about actual or perceived c#ange7 It is )ort ) ile to enco%rage t e $atient to se$arate feelings abo%t c anges in body str%ct%re and3or f%nction fro& feelings abo%t self:)ort (
Assist patient in incorporating actual c#anges into AD5s, social life, interpersonal relations#ips, and occupational activities7 O$$ort%nities for $ositi+e feedback and s%ccess in social sit%ations &ay asten ada$tation(
Demonstrate positive caring in routine activities7 4rofessional caregi+ers re$resent a &icrocos& of society' and t eir actions and be a+iors are scr%tini7ed as t e $atient $lans to ret%rn to o&e' to )ork' and to ot er acti+ities(
"eac# patient about t#e normalcy of body image disturbance and t#e grief process7
?:
"eac# patient adaptive be#avior (e7g7, use of adaptive e/uipment, ,igs, cosmetics, clot#ing t#at conceals altered body part or en#ances remaining part or function, use of deodorants)7 T is co&$ensates for act%al c anged body str%ct%re and f%nction(
)elp patient identify ,ays of coping t#at #ave been useful in t#e past7 Asking $atients to re&e&ber ot er body i&age iss%es -e(g(' getting glasses' )earing ort odontics' being $regnant' a+ing a leg cast. and o) t ey )ere &anaged &ay el$ $atient ad,%st to t e c%rrent iss%e(
Refer patient and caregivers to support groups composed of individuals ,it# similar alterations7 8ay $ersons in si&ilar sit%ations offer a different ty$e of s%$$ort' ) ic is $ercei+ed as el$f%l -e(g(' United Osto&y Association' C 6eD' I Can Co$e' 6ended /earts.(
Ineffecti+e Co$ing

Coping Decision 2aking %nformation *rocessing
Coping $n#ancement
NANDA Definition: %nability to form a valid appraisal of t#e stressors, inade/uate c#oices of practiced responses, and/or inability to use available resources For most persons, everyday life includes its s#are of stressors and demands, ranging from family, ,ork, and professional role responsibilities to ma&or life events suc# as divorce, illness, and t#e deat# of loved ones7 )o, one responds to suc# stressors depends on t#e personBs coping resources7 Suc# resources can include optimistic beliefs, social support net,orks, personal #ealt# and energy,
?9
problem+solving skills, and material resources7 Sociocultural and religious factors may influence #o, people vie, and #andle t#eir problems7 Some cultures may prefer privacy and avoid s#aring t#eir fears in public, even to #ealt# care providers7 As resources become limited and problems become more acute, t#is strategy may prove ineffective7 3ulnerable populations suc# as elderly patients, t#ose in adverse socioeconomic situations, t#ose ,it# comple! medical problems suc# as substance abuse, or t#ose ,#o find t#emselves suddenly p#ysically c#allenged may not #ave t#e resources or skills to cope ,it# t#eir acute or c#ronic stressors7 Suc# problems can occur in any setting (e7g7, during #ospitali1ation for an acute event, in t#e #ome or re#abilitation environment as a result of c#ronic illness, or in response to anot#er t#reat or loss)7 Defining C aracteristics: 3erbali1ation of inability to cope, %nability to make decisions, %nability to ask for #elp, Destructive be#avior to,ard self, %nappropriate use of defense mec#anisms, *#ysical symptoms suc# as t#e follo,ing 0vereating or lack of appetite, 0veruse of tran/uili1ers, $!cessive smoking and drinking, C#ronic fatigue, )eadac#es, %rritable bo,el, C#ronic depression,$motional tension, )ig# illness rate, %nsomnia, (eneral irritability Related !actors: C#ange in or loss of body part, Diagnosis of serious illness, Recent c#ange in #ealt# status, -nsatisfactory support system, %nade/uate psyc#ological resources (poor self+ esteem, lack of motivation), *ersonal vulnerability, %nade/uate coping met#od, Situational crises, 2aturational crises "#$ected O%tco&es: *atient identifies o,n maladaptive coping be#aviors7 *atient identifies available resources and support systems7 *atient describes and initiates alternative coping strategies7 *atient describes positive results from ne, be#aviors7 Ongoing Assess&ent
Assess for presence of defining c#aracteristics7 @e a+ioral and $ ysiological res$onses to stress can be +aried and $ro+ide cl%es to t e le+el of co$ing diffic%lty(
?;
Assess specific stressors7 Acc%rate a$$raisal can facilitate de+elo$&ent of a$$ro$riate co$ing strategies( @eca%se a $atient as an altered ealt stat%s does not &ean t e co$ing diffic%lties e or s e e# ibits are only -if at all. related to t at(
Assess available or useful past and present coping mec#anisms7 S%ccessf%l ad,%st&ent is infl%enced by $re+io%s co$ing s%ccess( 4atients )it inade*%ate in t e $resent sit%ation( istory of &alada$ti+e co$ing &ay need additional reso%rces( 8ike)ise' $re+io%sly s%ccessf%l co$ing skills &ay be
$valuate resources and support systems available to patient7 4atients &ay a+e s%$$ort in one setting' s%c as d%ring os$itali7ation' yet be disc arged o&e )it o%t s%fficient s%$$ort for effecti+e co$ing( Reso%rces &ay incl%de significant ot ers' ealt care $ro+iders s%c as o&e ealt n%rses' co&&%nity reso%rces' and s$irit%al co%nseling(
Assess level of understanding and readiness to learn needed lifestyle c#anges7 A$$ro$riate $roble& sol+ing re*%ires acc%rate infor&ation and %nderstanding of o$tions( Often $atients ) o are ineffecti+ely co$ing are %nable to ear or assi&ilate needed infor&ation(
Assess decision+making and problem+solving abilities7 4atients &ay feel t at t e t reat is greater t an t eir reso%rces to andle it and feel a loss of control o+er sol+ing t e t reat or $roble&(
$stablis# a ,orking relations#ip ,it# patient t#roug# continuity of care7 An ongoing relations i$ establis es tr%st' red%ces t e feeling of isolation' and &ay facilitate co$ing(
*rovide opportunities to e!press concerns, fears, feelings, and e!pectations7 5erbali7ation of act%al or $ercei+ed t reats can el$ red%ce an#iety( Convey feelings of acceptance and understanding7 Avoid false reassurances7 $ncourage patient to identify o,n strengt#s and abilities7 D%ring crises' $atients &ay not be able to recogni7e t eir strengt s( !ostering a)areness can e#$edite %se of t ese strengt s(
Assist patient to evaluate situation and o,n accomplis#ments accurately7 $!plore attitudes and feelings about re/uired lifestyle c#anges7 ?>
$ncourage patient to seek information t#at increases coping skills7 4atients ) o are not co$ing )ell &ay need &ore g%idance initially( *rovide information t#e patient ,ants and needs7 Do not provide more t#an patient can #andle7 4atients ) o are co$ing ineffecti+ely a+e red%ced ability to assi&ilate infor&ation(
$ncourage patient to set realistic goals7 T is el$s $atient gain control o+er t e sit%ation( G%iding t e $atient to +ie) t e sit%ation in s&aller $arts &ay &ake t e $roble& &ore &anageable(
Assist patient to problem solve in a constructive manner7 Discourage decision making ,#en under severe stress7 Reduce stimuli in environment t#at could be misinterpreted as t#reatening7 T is is es$ecially co&&on in t e ac%te os$ital setting ) ere $atients are e#$osed to ne) e*%i$&ent and en+iron&ents(
*rovide outlets t#at foster feelings of personal ac#ievement and self+esteem7 O$$ort%nities to role $lay or re earse a$$ro$riate actions can increase confidence for be a+ior in act%al sit%ation(
*oint out signs of positive progress or c#ange7 4atients ) o are co$ing ineffecti+ely &ay not be able to assess $rogress( $ncourage patient to communicate feelings ,it# significant ot#ers7 Une#$ressed feelings can increase stress( *oint out maladaptive be#aviors7 T is el$s $atient foc%s on &ore a$$ro$riate strategies( Administer tran/uili1er, sedative as ordered7 T ese facilitate ability to co$e( Assist to grieve and ,ork t#roug# t#e losses of c#ronic illness and c#ange in body function if appropriate7
%nstruct in need for ade/uate rest and balanced diet7 T ese facilitate co$ing strengt s( Inade*%ate diet and fatig%e can t e&sel+es be stressors( "eac# use of rela!ation, e!ercise, and diversional activities as met#ods to cope ,it# stress7
??
%nvolve social services, psyc#iatric liaison, and pastoral care for additional and ongoing support resources7 Assist in development of alternative support system7 $ncourage participation in self+#elp groups as available7 Relations i$s )it $ersons )it co&&on interests and goals can be beneficial(
Diarr ea
8oose Stools' Clostridium difficile (C. difficile) NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

'o,el $limination Fluid 'alance ?=
2edication Response

Diarr#ea 2anagement $nteral "ube Feeding "eac#ing *rescribed 2edications
NANDA Definition: *assage of loose, unformed stools Diarr#ea may result from a variety of factors, including intestinal absorption disorders, increased secretion of fluid by t#e intestinal mucosa, and #ypermotility of t#e intestine7 *roblems associated ,it# diarr#ea, ,#ic# may be acute or c#ronic, include fluid and electrolyte imbalance and altered skin integrity7 %n elderly patients, or t#ose ,it# c#ronic disease (e7g7, ac/uired immunodeficiency syndrome @A%DSA), diarr#ea can be life+t#reatening7 Diarr#ea may result from infectious (i7e7, viral, bacterial, or parasitic) processes< primary bo,el diseases (e7g7, Cro#nBs disease)< drug t#erapies (e7g7, antibiotics)< increased osmotic loads (e7g7, tube feedings)< radiation< or increased intestinal motility suc# as ,it# irritable bo,el disease7 "reatment is based on addressing t#e cause of t#e diarr#ea, replacing fluids and electrolytes, providing nutrition (if diarr#ea is prolonged and/or severe), and maintaining skin integrity7 )ealt# care ,orkers and ot#er caregivers must take precautions (e7g7, diligent #and ,as#ing bet,een patients) to avoid spreading diarr#ea from person to person, including self7 Defining C aracteristics: Abdominal pain, Cramping, Fre/uency of stools, 5oose or li/uid stools, -rgency, )yperactive bo,el sounds or sensations Related !actors: Stress, An!iety, 2edication use, 'o,el disorders inflammation, 2alabsorption, %ncreased secretion, $nteric infections, Disagreeable dietary intake, "ube feedings, Radiation, C#emot#erapy, 'o,el resection, S#ort bo,el syndrome, 5actose intolerance "#$ected O%tco&es: *atient passes soft, formed stool no more t#an t#ree times per day7
?C
Ongoing Assess&ent
Assess for abdominal pain, cramping, fre/uency, urgency, loose or li/uid stools, and #yperactive bo,el sensations7 Culture stool7 Testing )ill identify ca%sati+e organis&s( %n/uire about t#e follo,ing "olerance to milk and ot#er dairy products 4atients )it lactose intolerance a+e ins%fficient lactase' t e en7y&e t at digests lactose( T e $resence of lactose in t e intestines increases os&otic $ress%re and dra)s )ater into t e intestinal l%&en(
2edications patient is or #as been taking 8a#ati+es and antibiotics &ay ca%se diarr ea( C. difficile can coloni7e t e intestine follo)ing antibiotic %se and lead to $se%do&e&brano%s enterocolitis; C. difficile is a co&&on ca%se of nosoco&ial diarr ea in ealt care facilities(
%diosyncratic food intolerances S$icy' fatty' or ig :carbo ydrate foods &ay ca%se diarr ea( 2et#od of food preparation !ried food or food conta&inated )it bacteria d%ring $re$aration &ay ca%se diarr ea( 0smolality of tube feedings /y$eros&olar food or fl%id dra)s e#cess fl%id into t e g%t' sti&%lates $eristalsis' and ca%ses diarr ea( C#ange in eating sc#edule, 5evel of activity, Ade/uacy or privacy for elimination, Current stressors So&e indi+id%als res$ond to stress )it y$eracti+ity of t e GI tract( C#eck for #istory of t#e follo,ing
*revious gastrointestinal ((%) surgery !ollo)ing bo)el resection' a $eriod -; to 2 )eeks. of diarr ea is nor&al( (% diseases Abdominal radiation Radiation ca%ses slo%g ing of t e intestinal &%cosa' decreases %s%al absor$tion ca$acity' and &ay res%lt in diarr ea(
Assess impact of t#erapeutic or diagnostic regimens on diarr#ea7 4re$aration for radiogra$ y or s%rgery' and radiation or c e&ot era$y $redis$oses to diarr ea by altering &%cosal s%rface and transit ti&e t ro%g bo)el(
Assess #ydration status, as in t#e follo,ing
?D
%nput and output Diarr ea can lead to $rofo%nd de ydration and electrolyte i&balance( Skin turgor 2oisture of mucous membrane
Assess condition of perianal skin7 Diarr eal stools &ay be ig ly corrosi+e' as a res%lt of increased en7y&e content( $!plore emotional impact of illness, #ospitali1ation, and/or soiling accidents by providing privacy and opportunity for verbali1ation7
(ive antidiarr#eal drugs as ordered7 6ost antidiarr eal dr%gs s%$$ress GI &otility' t %s allo)ing for &ore fl%id absor$tion( *rovide t#e follo,ing dietary alterations as allo,ed

'ulk fiber (e7g7, cereal, grains, 2etamucil) G.aturalG antidiarr#eals (e7g7, pret1els, mat1os, c#eese) Avoidance of stimulants (e7g7, caffeine, carbonated beverages) Sti&%lants &ay increase GI &otility and )orsen diarr ea(
C#eck for fecal impaction by digital e!amination7 8i*%id stool -a$$arent diarr ea. &ay see$ $ast a fecal i&$action( $ncourage fluids< consider nutritional support7 !l%ids co&$ensate for &alabsor$tion and loss of n%trients( $valuate appropriateness of p#ysicianBs radiograp# protocols for bo,el preparation on basis of age, ,eig#t, condition, disease, and ot#er t#erapies7 "lderly' frail' or t ose $atients already de$leted &ay re*%ire less bo)el $re$aration or additional intra+eno%s -I5. fl%id t era$y d%ring $re$aration(
Assist ,it# or administer perianal care after eac# bo,el movement ('2)7 T is $re+ents $erianal skin e#coriation( For patients ,it# enteral tube feeding, employ t#e follo,ing
C#ange feeding tube e/uipment according to institutional policy, but no less t#an every ;? #ours7 Conta&inated e*%i$&ent can ca%se diarr ea(
?E
Administer tube feeding at room temperature7 "#tre&es of te&$erat%re can sti&%late $eristalsis( %nitiate tube feeding slo,ly7 Decrease rate or dilute feeding if diarr#ea persists or ,orsens7 T is $re+ents y$eros&olar diarr ea(
"eac# patient or caregiver t#e follo,ing dietary factors t#at can be controlled

Avoid spicy, fatty foods7 'roil, bake, or boil foods< avoid frying7 Avoid foods t#at are disagreeable7
$ncourage reporting of diarr#ea t#at occurs ,it# prescription drugs7 T ere are %s%ally se+eral antibiotics )it ) ic t e $atient can be treated; if t e one $rescribed ca%ses diarr ea' t is s o%ld be re$orted $ro&$tly(
"eac# patient or caregiver t#e follo,ing measures t#at control diarr#ea

"ake antidiarr#eal medications as ordered7 $ncourage use of GnaturalG antidiarr#eals (t#ese may differ person to person)7
"eac# patient or caregiver t#e importance of fluid replacement during diarr#eal episodes7 !l%ids $re+ent de ydration( "eac# patient or caregiver t#e importance of good perianal #ygiene after eac# '27 /ygiene controls $erianal skin e#coriation and &ini&i7es risk of s$read of infectio%s diarr ea(
?F
Deficient !l%id 5ol%&e

/y$o+ole&ia; De ydration NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Fluid 'alance )ydration

Fluid 2onitoring Fluid 2anagement Fluid Resuscitation
NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid7 "#is refers to de#ydration, ,ater loss alone ,it#out c#ange in sodium Fluid volume deficit, or #ypovolemia, occurs from a loss of body fluid or t#e s#ift of fluids into t#e t#ird space, or from a reduced fluid intake7 Common sources for fluid loss are t#e gastrointestinal ((%) tract, polyuria, and increased perspiration7 Fluid volume deficit may be an acute or c#ronic condition managed in t#e #ospital, outpatient center, or #ome setting7 "#e t#erapeutic goal is to treat t#e underlying disorder and return t#e e!tracellular fluid compartment to normal7 "reatment consists of restoring fluid volume and correcting any electrolyte imbalances7 $arly recognition and treatment are paramount to prevent potentially life+t#reatening #ypovolemic s#ock7 $lderly patients are more likely to develop fluid imbalances7 Defining C aracteristics: Decreased urine output, Concentrated urine, 0utput greater t#an intake, Sudden ,eig#t loss, Decreased venous filling, )emoconcentration, %ncreased serum sodium, )ypotension, "#irst, %ncreased pulse rate, Decreased skin turgor, Dry mucous membranes, 4eakness, *ossible ,eig#t gain, C#anges in mental status
=:
Related !actors: %nade/uate fluid intake, Active fluid loss (diuresis, abnormal drainage or bleeding, diarr#ea), Failure of regulatory mec#anisms, $lectrolyte and acid+base imbalances, %ncreased metabolic rate (fever, infection), Fluid s#ifts (edema or effusions) "#$ected O%tco&es : *atient e!periences ade/uate fluid volume and electrolyte balance as evidenced by urine output greater t#an >: ml/#r, normotensive blood pressure ('*), #eart rate ()R) 9:: beats/min, consistency of ,eig#t, and normal skin turgor7 Ongoing Assess&ent
0btain patient #istory to ascertain t#e probable cause of t#e fluid disturbance7 T is can el$ to g%ide inter+entions( Ca%ses &ay incl%de ac%te tra%&a and bleeding' red%ced fl%id intake fro& c anges in cognition' large a&o%nt of drainage $ost:s%rgery' or $ersistent diarr ea(
Assess or instruct patient to monitor ,eig#t daily and consistently, ,it# same scale, and preferably at t#e same time of day7 T is facilitates acc%rate &eas%re&ent and follo)s trends(
$valuate fluid status in relation to dietary intake7 Deter&ine if $atient as been on a fl%id restriction( 6ost fl%id enters t e body t ro%g drinking' )ater in foods' and )ater for&ed by o#idation of foods(
2onitor and document vital signs7 Sin%s tac ycardia &ay occ%r )it
y$o+ole&ia to
&aintain an effecti+e cardiac o%t$%t( Us%ally t e $%lse is )eak' and &ay be irreg%lar if electrolyte i&balance also occ%rs( /y$otension is e+ident in y$o+ole&ia(
2onitor blood pressure for ort#ostatic c#anges (from patient lying supine to #ig#+ Fo,lerBs)7 Note t e follo)ing ort ostatic y$otension significance:

Greater t an ;1 && /g dro$: circ%lating blood +ol%&e is decreased by 01?( Greater t an 01 to 21 && /g dro$: circ%lating blood +ol%&e is decreased by A1?(
Assess skin turgor and mucous membranes for signs of de#ydration7 T e skin in elderly $atients loses its elasticity; t erefore skin t%rgor s o%ld be assessed o+er t e stern%& or on t e inner t ig s( 8ongit%dinal f%rro)s &ay be noted along t e tong%e(
=9
Assess color and amount of urine7 Report urine output less t#an >: ml/#r for ; consecutive #ours7 Concentrated %rine denotes fl%id deficit( 2onitor temperature7 !ebrile states decrease body fl%ids t ro%g $ers$iration and increased res$iration( 2onitor active fluid loss from ,ound drainage, tubes, diarr#ea, bleeding, and vomiting< maintain accurate input and output7 2onitor serum electrolytes and urine osmolality and report abnormal values7 "le+ated e&oglobin and ele+ated blood %rea nitrogen -@UN. s%ggest fl%id deficit( Urine: s$ecific gra+ity is like)ise increased(
Document baseline mental status and record during eac# nursing s#ift7 De ydration can alter &ental stat%s( $valuate ,#et#er patient #as any related #eart problem before initiating parenteral t#erapy7 Cardiac and elderly $atients often a+e $recario%s fl%id balances and are $rone to de+elo$ $%l&onary ede&a(
Determine patientBs fluid preferences type, temperature (#ot or cold)7 During treatment, monitor closely for signs of circulatory overload (#eadac#e, flus#ed skin, tac#ycardia, venous distention, elevated central venous pressure @C3*A, s#ortness of breat#, increased '*, tac#ypnea, coug#)7 T is $re+ents co&$lications associated )it t era$y(
%f #ospitali1ed, monitor #emodynamic status including C3*, pulmonary artery pressure (*A*), and pulmonary capillary ,edge pressure (*C4*) if available7 T is direct &eas%re&ent ser+es as o$ti&al g%ide for t era$y(
$ncourage patient to drink prescribed fluid amounts7
%f oral fluids are tolerated, provide oral fluids patient prefers7 *lace at bedside ,it#in easy reac#7 *rovide fres# ,ater and a stra,7 'e creative in selecting fluid sources (e7g7, flavored gelatin, fro1en &uice bars, sports drink)7
Oral fl%id re$lace&ent is indicated for &ild fl%id deficit( "lderly $atients a+e a decreased sense of t irst and &ay need ongoing re&inders to drink(
=;
Assist patient if unable to feed self and encourage caregiver to assist ,it# feedings as appropriate7 *lan daily activities7 4lanning $re+ents $atient fro& being too tired at &ealti&es( *rovide oral #ygiene7 T is $ro&otes interest in drinking( !or &ore se+ere y$o+ole&ia:
0btain and maintain a large+bore intravenous (%3) cat#eter7 4arenteral fl%id re$lace&ent is indicated to $re+ent s ock( Administer parenteral fluids as ordered7 Anticipate t#e need for an %3 fluid c#allenge ,it# immediate infusion of fluids for patients ,it# abnormal vital signs7 Administer blood products as prescribed7 T ese &ay be re*%ired for acti+e GI bleeding( Assist t#e p#ysician ,it# insertion of a central venous line and arterial line as indicated7 T is allo)s &ore effecti+e fl%id ad&inistration and &onitoring( 2aintain %3 flo, rate7
S#ould signs of fluid overload occur, stop infusion and sit patient up or dangle7 T ese decrease +eno%s ret%rn and o$ti&i7e breat ing(
"lderly $atients are es$ecially s%sce$tible to fl%id o+erload(
%nstitute measures to control e!cessive electrolyte loss (e7g7, resting t#e (% tract, administering antipyretics as ordered)7 0nce ongoing fluid losses #ave stopped, begin to advance t#e diet in volume and composition7 For #ypovolemia due to severe diarr#ea or vomiting, administer antidiarr#eal or antiemetic medications as prescribed, in addition to %3 fluids7

Describe or teac# causes of fluid losses or decreased fluid intake7 $!plain or reinforce rationale and intended effect of treatment program7 $!plain importance of maintaining proper nutrition and #ydration7
=>
"eac# interventions to prevent future episodes of inade/uate intake7 4atients need to %nderstand t e i&$ortance of drinking e#tra fl%id d%ring bo%ts of diarr ea' fe+er' and ot er conditions ca%sing fl%id deficits(
%nform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved7 %f patients are to receive %3 fluids at #ome, instruct caregiver in managing %3 e/uipment7 Allo, sufficient time for return demonstration7 Res$onsibility for &aintaining +eno%s access sites and I5 s%$$lies &ay be o+er) el&ing for caregi+er( In addition' elderly caregi+ers &ay not a+e t e cogniti+e ability and &an%al de#terity re*%ired for t is t era$y(
Refer to #ome #ealt# nurse as appropriate7
I&$aired Gas "#c ange

5entilation or 4erf%sion I&balance NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Respiratory Status (as $!c#ange
=?
Respiratory 2onitoring 0!ygen "#erapy Air,ay 2anagement
NANDA Definition: $!cess or deficit in o!ygenation and/or carbon dio!ide elimination at t#e alveolar+capillary membrane 'y t#e process of diffusion t#e e!c#ange of o!ygen and carbon dio!ide occurs in t#e alveolar+ capillary membrane area7 "#e relations#ip bet,een ventilation (airflo,) and perfusion (blood flo,) affects t#e efficiency of t#e gas e!c#ange7 .ormally t#ere is a balance bet,een ventilation and perfusion< #o,ever, certain conditions can offset t#is balance, resulting in impaired gas e!c#ange7 Altered blood flo, from a pulmonary embolus, or decreased cardiac output or s#ock can cause ventilation ,it#out perfusion7 Conditions t#at cause c#anges or collapse of t#e alveoli (e7g7, atelectasis, pneumonia, pulmonary edema, and adult respiratory distress syndrome @ARDSA) impair ventilation7 0t#er factors affecting gas e!c#ange include #ig# altitudes, #ypoventilation, and altered o!ygen+carrying capacity of t#e blood from reduced #emoglobin7 $lderly patients #ave a decrease in pulmonary blood flo, and diffusion as ,ell as reduced ventilation in t#e dependent regions of t#e lung ,#ere perfusion is greatest7 C#ronic conditions suc# as c#ronic obstructive pulmonary disease (C0*D) put t#ese patients at greater risk for #ypo!ia7 0t#er patients at risk for impaired gas e!c#ange include t#ose ,it# a #istory of smoking or pulmonary problems, obesity, prolonged periods of immobility, and c#est or upper abdominal incisions7 Defining C aracteristics: Confusion, Somnolence, Restlessness, %rritability, %nability to move secretions, )ypercapnia, )ypo!ia Related !actors: Altered o!ygen supply, Alveolar+capillary membrane c#anges, Altered blood flo,, Altered o!ygen+carrying capacity of blood "#$ected O%tco&es *atient maintains optimal gas e!c#ange as evidenced by normal arterial blood gases (A'(s) and alert responsive mentation or no furt#er reduction in mental status7
==
Ongoing Assess&ent
Assess respirations note /uality, rate, pattern, dept#, and breat#ing effort7 @ot ra$id' s allo) breat ing $atterns and y$o+entilation affect gas e#c ange( S allo)' Esig lessE breat ing $atterns $osts%rgery -as a res%lt of effect of anest esia' $ain' and i&&obility. red%ce l%ng +ol%&e and decrease +entilation(
Assess lung sounds, noting areas of decreased ventilation and t#e presence of adventitious sounds7 Assess for signs and symptoms of #ypo!emia tac#ycardia, restlessness, diap#oresis, #eadac#e, let#argy, and confusion7 Assess for signs and symptoms of atelectasis diminis#ed c#est e!cursion, limited diap#ragm e!cursion, bronc#ial or tubular breat# sounds, rales, trac#eal s#ift to affected side7 Colla$se of al+eoli increases $ ysiological s %nting(
Assess for signs or symptoms of pulmonary infarction coug#, #emoptysis, pleuritic pain, consolidation, pleural effusion, bronc#ial breat#ing, pleural friction rub, fever7 2onitor vital signs7 Wit initial y$o#ia and y$erca$nia' blood $ress%re -@4.' eart rate' and res$iratory rate all rise( As t e y$o#ia and3or y$erca$nia beco&es &ore se+ere' @4 &ay dro$' eart rate tends to contin%e to be ra$id )it arr yt &ias' and res$iratory fail%re &ay ens%e )it t e $atient %nable to &aintain t e ra$id res$iratory rate(
Assess for c#anges in orientation and be#avior7 Restlessness is an early sign of y$o#ia( C ronic y$o#e&ia &ay res%lt in cogniti+e c anges s%c as &e&ory c anges( 2onitor A'(s and note c#anges7 Increasing 4aCO0 and decreasing 4aO0 are signs of res$iratory fail%re( As t e $atient begins to fail' t e res$iratory rate )ill decrease and 4aCO0 )ill begin to rise( So&e $atients' s%c as t ose )it CO4D' a+e a significant decrease in $%l&onary reser+es' and any $ ysiological stress &ay res%lt in ac%te res$iratory fail%re(
-se pulse o!imetry to monitor o!ygen saturation and pulse rate7 4%lse o#i&etry is a %sef%l tool to detect c anges in o#ygenation( O#ygen sat%ration s o%ld be &aintained at F1? or greater( T is tool can be es$ecially el$f%l in t e o%t$atient or re abilitation setting ) ere $atients at risk for desat%ration fro& c ronic $%l&onary diseases can
=C
&onitor t e effects of e#ercise or acti+ity on t eir o#ygen sat%ration le+els( /o&e o#ygen t era$y can t en be $rescribed as indicated( 4atients s o%ld be assessed for t e need for o#ygen bot at rest and )it acti+ity( A ig er liter flo) of o#ygen is generally re*%ired for acti+ity +ers%s rest -e(g(' 0 8 at rest' and A 8 )it acti+ity.( 6edicare g%idelines for rei&b%rse&ent for o&e o#ygen re*%ire a 4aCO0 less t an >B and3or o#ygen sat%ration of BB? or less on roo& air( O#ygen deli+ery is t en titrated to &aintain an o#ygen sat%ration of F1? or greater(
Assess skin color for development of cyanosis7 !or cyanosis to be $resent' > g of e&oglobin &%st desat%rate( 2onitor c#est !+ray reports7 C est #:rays &ay g%ide t e etiological factors of t e i&$aired gas e#c ange( Gee$ in &ind t at radiogra$ ic st%dies of l%ng )ater lag be ind clinical $resentation by 0A o%rs(
2onitor effects of position c#anges on o!ygenation (Sa0;, A'(s, S30;, and end+tidal C0;)7 4%tting t e &ost congested l%ng areas in t e de$endent $osition -) ere $erf%sion is greatest. $otentiates +entilation and $erf%sion i&balances(
Assess patientBs ability to coug# effectively to clear secretions7 .ote /uantity, color, and consistency of sputum7 Retained secretions i&$air gas e#c ange(
2aintain o!ygen administration device as ordered, attempting to maintain o!ygen saturation at F:H or greater7 T is $ro+ides for ade*%ate o#ygenation( Avoid #ig# concentration of o!ygen in patients ,it# C0*D7 /y$o#ia sti&%lates t e dri+e to breat e in t e c ronic CO0 retainer $atient( W en a$$lying o#ygen' close &onitoring is i&$erati+e to $re+ent %nsafe increases in t e $atient<s 4aO0' ) ic co%ld res%lt in a$nea( .0"$ %f t#e patient is allo,ed to eat, o!ygen still must be given to t#e patient but in a different manner (e7g7, c#anging from mask to a nasal cannula)7 "ating is an acti+ity and &ore o#ygen )ill be cons%&ed t an ) en t e $atient is at rest( I&&ediately after t e &eal' t e original o#ygen deli+ery syste& s o%ld be ret%rned( =D
For patients ,#o s#ould be ambulatory, provide e!tension tubing or portable o!ygen apparatus7 T ese $ro&ote acti+ity and facilitate &ore effecti+e +entilation( *osition ,it# proper body alignment for optimal respiratory e!cursion (if tolerated, #ead of bed at ?= degrees)7 T is $ro&otes l%ng e#$ansion and i&$ro+es air e#c ange( Routinely c#eck t#e patientBs position so t#at #e or s#e does not slide do,n in bed7 T is )o%ld ca%se t e abdo&en to co&$ress t e dia$ rag&' ) ic )o%ld ca%se res$iratory e&barrass&ent(
*osition patient to facilitate ventilation/perfusion matc#ing7 -se uprig#t, #ig#+Fo,lerBs position ,#enever possible7 /ig :!o)ler<s $osition allo)s for o$ti&al dia$ rag& e#c%rsion( W en $atient is $ositioned on side' t e good side s o%ld be do)n -e(g(' l%ng )it $%l&onary e&bol%s or atelectasis s o%ld be %$.(
*ace activities and sc#edule rest periods to prevent fatigue7 "+en si&$le acti+ities s%c as bat ing d%ring bed rest can ca%se fatig%e and increase o#ygen cons%&$tion( C#ange patientBs position every ; #ours7 T is facilitates secretion &o+e&ent and drainage( Suction as needed7 S%ction clears secretions if t e $atient is %nable to effecti+ely clear t e air)ay( $ncourage deep breat#ing, using incentive spirometer as indicated7 T is red%ces al+eolar colla$se( For postoperative patients, assist ,it# splinting t#e c#est7 S$linting o$ti&i7es dee$ breat ing and co%g ing efforts( $ncourage or assist ,it# ambulation as indicated7 T is $ro&otes l%ng e#$ansion' facilitates secretion clearance' and sti&%lates dee$ breat ing( *rovide reassurance and allay an!iety

)ave an agreed+on met#od for t#e patient to call for assistance (e7g7, call lig#t, bell)7 Stay ,it# t#e patient during episodes of respiratory distress7
Anticipate need for intubation and mec#anical ventilation if patient is unable to maintain ade/uate gas e!c#ange7 "arly int%bation and &ec anical +entilation are reco&&ended to $re+ent f%ll deco&$ensation of t e $atient( 6ec anical +entilation $ro+ides s%$$orti+e care to &aintain ade*%ate o#ygenation and +entilation to t e $atient(
=E
Treat&ent also needs to foc%s on t e %nderlying ca%sal factor leading to res$iratory fail%re(
Administer medications as prescribed7 T e ty$e de$ends on t e etiological factors of t e $roble& -e(g(' antibiotics for $ne%&onia' bronc odilators for CO4D' anticoag%lants3t ro&bolytics for $%l&onary e&bol%s' analgesics for t oracic $ain.(
$!plain t#e need to restrict and pace activities to decrease o!ygen consumption during t#e acute episode7 $!plain t#e type of o!ygen t#erapy being used and ,#y its maintenance is important7 Iss%es related to o&e o#ygen %se' storage' or $reca%tions need to be addressed( "eac# t#e patient appropriate deep breat#ing and coug#ing tec#ni/ues7 T ese facilitate ade*%ate air e#c ange and secretion clearance( Assist patient in obtaining #ome nebuli1er, as appropriate, and instruct in its use in collaboration ,it# respiratory t#erapist7 Refer to #ome #ealt# services for nursing care or o!ygen management as appropriate7
Ineffecti+e /ealt 6aintenance


)ealt#+*romoting 'e#avior Self+Direction of Care )ealt#+Seeking 'e#avior Social Support

)ealt# System (uidance Support System $n#ancement
=F
Disc#arge *lanning )ealt# Screening Risk %dentification
NANDA Definition: %nability to identify, manage, and/or seek #elp to maintain #ealt# Altered #ealt# maintenance reflects a c#ange in an individualBs ability to perform t#e functions necessary to maintain #ealt# or ,ellness7 "#at individual may already manifest symptoms of e!isting or impending p#ysical ailment or display be#aviors t#at are strongly or certainly linked to disease7 "#e nurseBs role is to identify factors t#at contribute to an individualBs inability to maintain #ealt#y be#avior and implement measures t#at ,ill result in improved #ealt# maintenance activities7 "#e nurse may encounter patients ,#o are e!periencing an alteration in t#eir ability to maintain #ealt# eit#er in t#e #ospital or in t#e community, but t#e increased presence of t#e nurse in t#e community and #ome #ealt# settings improves t#e ability to assess patients in t#eir o,n environment7 *atients most likely to e!perience more t#an transient alterations in t#eir ability to maintain t#eir #ealt# are t#ose ,#ose age or infirmity (eit#er p#ysical or emotional) absorb muc# of t#eir resources7 "#e task before t#e nurse is to identify measures t#at ,ill be successful in empo,ering patients to maintain t#eir o,n #ealt# ,it#in t#e limits of t#eir ability7 Defining C aracteristics: @e a+ioral c aracteristics: Demonstrated lack of kno,ledge, Failure to keep appointments, $!pressed interest in improving be#aviors, Failure to recogni1e or respond to important symptoms reflective of c#anging #ealt# state, %nability to follo, instructions or programs for #ealt# maintenance 4 ysical c aracteristics: 'ody or mout# odor, -nusual skin color, pallor, *oor #ygiene , Soiled clot#ing, Fre/uent infections (e7g7, upper respiratory infection @-R%A, urinary tract infection @-"%A), Fre/uent toot#ac#es , 0besity or anore!ia, Anemia, C#ronic fatigue, Apat#etic attitude, Substance abuse
C:
Related !actors: *resence of mental retardation, illness, organic brain syndrome,*resence of p#ysical disabilities or c#allenges, *resence of adverse personal #abits Smoking, *oor diet selection, 2orbid obesity, Alco#ol abuse, Drug abuse, *oor #ygiene, 5ack of e!ercise, $vidence of impaired perception, 5o, income, 5ack of kno,ledge, *oor #ousing conditions, Risk+taking be#aviors, %nability to communicate needs ade/uately (e7g7, deafness, speec# impediment), Dramatic c#ange in #ealt# status, 5ack of support systems, Denial of need to c#ange current #abits "#$ected O%tco&es: *atient describes positive #ealt# maintenance be#aviors suc# as keeping sc#eduled appointments, participating in smoking and substance abuse programs, making diet and e!ercise c#anges, improving #ome environment, and follo,ing treatment regimen7 *atient identifies available resources7 *atient uses available resources7 Ongoing Assess&ent
Assess for p#ysical defining c#aracteristics7 C anging ability or interest in $erfor&ing t e nor&al acti+ities of daily li+ing -AD8s. &ay be an indicator t at co&&it&ent to ealt and )ell:being is )aning(
Assess patientBs kno,ledge of #ealt# maintenance be#aviors7 4atients &ay kno) t at certain %n ealt y be a+iors can res%lt in $oor ealt o%tco&es b%t contin%e t e be a+ior des$ite t is kno)ledge( T e ealt care $ro+ider needs to ens%re t at t e $atient as all of t e infor&ation needed to &ake good lifestyle c oices(
Assess #ealt# #istory over past = years7 T is &ay gi+e so&e $ers$ecti+e on ) et er $oor ealt abits are recent or c ronic in nat%re( Assess to ,#at degree environmental, social, intrafamilial disruptions, or c#anges #ave correlated ,it# poor #ealt# be#aviors7 T ese c anges &ay be $reci$itating factors or &ay be early fallo%t fro& a generali7ed condition reflecting decline(
Determine patientBs specific /uestions related to #ealt# maintenance7 4atients &ay a+e ealt ed%cation needs; &eeting t ese needs &ay be el$f%l in &obili7ing t e $atient( Determine patientBs motives for failing to report symptoms reflecting c#anges in #ealt# status7 4atient &ay not )ant to Ebot erE t e $ro+ider' or &ay &ini&i7e t e i&$ortance of t e sy&$to&s(
C9
Discuss noncompliance ,it# instructions or programs ,it# patient to determine rationale for failure7 4atient &ay be e#$eriencing obstacles in co&$liance t at can be resol+ed( Assess t#e patientBs educational preparation and ability to integrate and relate to information7 4atients &ay not a+e %nderstood infor&ation beca%se of a sensory i&$air&ent or t e inability to read or %nderstand infor&ation( C%lt%re or age &ay i&$air a $atient<s ability to co&$ly )it t e establis ed treat&ent $lan(
Assess #istory of ot#er adverse personal #abits, including t#e follo,ing smoking, obesity, lack of e!ercise, and alco#ol or substance abuse7 8ong:standing abits &ay be diffic%lt to break; once establis ed' $atients &ay feel t at not ing $ositi+e can co&e fro& a c ange in be a+ior(
Determine ,#et#er t#e patientBs manual de!terity or lack of mobility is a factor in patientBs altered capacity for #ealt# maintenance7 4atients &ay need assisti+e de+ices for a&b%lation or to co&$lete tasks of daily li+ing(
Determine to ,#at degree patientBs cultural beliefs and personality contribute to altered #ealt# #abits7 /ealt teac ing &ay need to be &odified to be consistent )it c%lt%ral or religio%s beliefs(
Determine ,#et#er t#e re/uired #ealt# maintenance facilities/e/uipment (e7g7, access ramps, motor ve#icle modifications, s#o,er bar or c#air) are available to patient7 Wit ade*%ate assisti+e de+ices' t e $atient &ay be able to effect enor&o%s c anges in &aintaining is or er $ersonal ealt (
Assess ,#et#er economic problems present a barrier to maintaining #ealt# be#aviors7 4atients &ay be too $ro%d to ask for assistance or be %na)are t at Social Sec%rity' 6edicare' or ins%rance benefits co%ld be el$f%l to t e&(
Assess #earing, and orientation to time, place, and person to determine t#e patientBs perceptual abilities7 4erce$t%al andica$s &ay i&$air an indi+id%al<s ability to &aintain ealt y be a+iors(
2ake a #ome visit to determine safety, accessibility, and /uality of living conditions7 T is )ill el$ identify and sol+e $roble&s t at co&$licate ealt &aintenance( Assess patientBs e!perience of stress and disruptors as t#ey relate to #ealt# #abits7 If stressors can be relie+ed' $atients &ay again be able to res%&e t eir self:care acti+ities(
C;
Follo, up on clinic visits ,it# telep#one or #ome visits7 T is )ill de+elo$ an ongoing relations i$ )it $atient and $ro+ide ongoing s%$$ort( *rovide patient ,it# a means of contacting #ealt# care providers7 T is )ill add a+ailable reso%rces for *%estions or $roble& resol%tion( Compliment patient on positive accomplis#ments7 4ositi+e reinforce&ent en ances be a+ior c ange( %nvolve family and friends in #ealt# planning conferences7 !a&ily &e&bers need to %nderstand t at care is $lanned to foc%s on ) at is &ost i&$ortant to t e $atient( T is enables t e $atient to &aintain a sense of a%tono&y(
*rovide assistive devices (e7g7, ,alker, cane, ,#eelc#air) as necessary7 T ese $ro&ote inde$endence and a sense of a%tono&y(

*rovide patient ,it# rationale for importance of be#aviors suc# as t#e follo,ing 'alanced diet lo, in c#olesterol T is $re+ents +asc%lar disease( Smoking cessation S&oking as been directly linked to cancer and eart disease( Cessation of alco#ol and drug abuse In addition to $ ysical addictions and t e social conse*%ences' t e $ ysical conse*%ences of s%bstance ab%se &itigate against it( Regular e!ercise T is $ro&otes )eig t loss and increases agility and sta&ina( *roper #ygiene T is decreases risk of infection and $ro&otes &aintenance and integrity of skin and teet ( Regular p#ysical and dental c#eckups C eck%$s identify and treat $roble&s early( Reporting of unusual symptoms to a #ealt# professional T is initiates early treat&ent( *roper nutrition, Regular inoculations, $arly and regular prenatal care $nsure t#at ot#er agencies (e7g7, Department of C#ildren and Family Services @DCFSA, Social Services, 3isiting .urse Association @3.AA, 2eals+on+4#eels) are follo,ing t#roug# ,it# plans7 Coordinated efforts are &ore &eaningf%l and effecti+e(
C>
Risk for Infection

Uni+ersal 4reca%tions; Standard 4reca%tions; CDC G%idelines; OS/A NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

%mmune Status 6no,ledge %nfection Control

%nfection Control %nfection *rotection
NANDA Definition: At increased risk for being invaded by pat#ogenic organisms *ersons at risk for infection are t#ose ,#ose natural defense mec#anisms are inade/uate to protect t#em from t#e inevitable in&uries and e!posures t#at occur t#roug#out t#e course of living7 %nfections occur ,#en an organism (e7g7, bacterium, virus, fungus, or ot#er parasite) invades a susceptible #ost7 'reaks in t#e integument, t#e bodyBs first line of defense, and/or t#e mucous membranes allo, invasion by pat#ogens7 %f t#e #ostBs (patientBs) immune system cannot combat t#e invading organism ade/uately, an infection occurs7 0pen ,ounds, traumatic or surgical, can be sites for infection< soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection eit#er after trauma, invasive procedures, or by invasion of pat#ogens carried t#roug# t#e bloodstream or lymp#atic system7 %nfections can be transmitted, eit#er by contact or t#roug# airborne transmission, se!ual contact, or s#aring of intravenous (%3) drug parap#ernalia7 'eing malnouris#ed, #aving inade/uate resources for sanitary living conditions, and lacking kno,ledge about disease transmission place individuals at risk for infection7 )ealt# care ,orkers, to protect t#emselves and ot#ers from disease transmission, must understand #o, to take precautions to prevent transmission7 'ecause identification of infected individuals is not al,ays apparent, standard precautions recommended by t#e Centers for Disease Control and *revention (CDC) are ,idely practiced7 %n addition, t#e 0ccupational Safety and )ealt# Administration (0S)A) #as set
C?
fort# t#e 'lood 'orne *at#ogens Standard, developed to protect ,orkers and t#e public from infection7 $ase and increase in ,orld travel #as also increased opportunities for transmission of disease from abroad7 %nfections prolong #ealing, and can result in deat# if untreated7 Antimicrobials are used to treat infections ,#en susceptibility is present7 0rganisms may become resistant to antimicrobials, re/uiring multiple antimicrobial t#erapy7 "#ere are organisms for ,#ic# no antimicrobial is effective, suc# as t#e #uman immunodeficiency virus ()%3)7 Risk !actors: %nade/uate primary defenses broken skin, in&ured tissue, body fluid stasis7 %nade/uate secondary defenses immunosuppression, leucopenia, 2alnutrition, %ntubation, %nd,elling cat#eters, drains, %ntravenous (%3) devices, %nvasive procedures, Rupture of amniotic membranes, C#ronic disease, Failure to avoid pat#ogens (e!posure), %nade/uate ac/uired immunity "#$ected O%tco&es: *atient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from ,ounds, incisions, and tubes7 %nfection is recogni1ed early to allo, for prompt treatment7 Ongoing Assess&ent
Assess for presence, e!istence of, and #istory of risk factors suc# as open ,ounds and abrasions< in+d,elling cat#eters (Foley, peritoneal)< ,ound drainage tubes ("+tubes, *enrose, Jackson+*ratt)< endotrac#eal or trac#eostomy tubes< venous or arterial access devices< and ort#opedic fi!ator pins7 "ac of t ese e#a&$les re$resent a break in t e body<s nor&al first lines of defense(
2onitor ,#ite blood count (4'C)7 Rising W@C indicates body<s efforts to co&bat $at ogens; nor&al +al%es: A111 to ;;'111 &&2( 5ery lo) W@C -ne%tro$enia H;111 &&2. indicates se+ere risk for infection beca%se $atient does not a+e s%fficient W@Cs to fig t infection( NOT": In elderly $atients' infection &ay be $resent )it o%t an increased W@C(
2onitor t#e follo,ing for signs of infection
C=
Redness, s,elling, increased pain, or purulent drainage at incisions, in&ured sites, e!it sites of tubes, drains, or cat#eters Any s%s$icio%s drainage s o%ld be c%lt%red; antibiotic t era$y is deter&ined by $at ogens identified at c%lt%re(
$levated temperature !e+er of %$ to 2BI C -;11(AI !. for AB o%rs after s%rgery is related to s%rgical stress; after AB o%rs' fe+er abo+e 2J(JI C -FF(BI !. s%ggests infection; fe+er s$ikes t at occ%r and s%bside are indicati+e of )o%nd infection; +ery ig fe+er acco&$anied by s)eating and c ills &ay indicate se$tice&ia(
Color of respiratory secretions Cello) or yello):green s$%t%& is indicati+e of res$iratory infection( Appearance of urine Clo%dy' fo%l:s&elling %rine )it +isible sedi&ent is indicati+e of %rinary tract or bladder infection( Assess nutritional status, including ,eig#t, #istory of ,eig#t loss, and serum albumin7 4atients )it $oor n%tritional stat%s &ay be anergic' or %nable to &%ster a cell%lar i&&%ne res$onse to $at ogens and are t erefore &ore s%sce$tible to infection(
%n pregnant patients, assess intactness of amniotic membranes7 4rolonged r%$t%re of a&niotic &e&branes before deli+ery $laces t e &ot er and infant at increased risk for infection(
Assess for e!posure to individuals ,it# active infections7 Assess for #istory of drug use or treatment modalities t#at may cause immunosuppression7 Antineo$lastic agents and corticosteroids red%ce i&&%noco&$etence( Assess immuni1ation status7 "lderly $atients and t ose not raised in t e United States &ay not a+e co&$leted i&&%ni7ations' and t erefore not a+e s%fficient ac*%ired i&&%noco&$etence(
2aintain or teac# asepsis for dressing c#anges and ,ound care, cat#eter care and #andling, and perip#eral %3 and central venous access management7 4as# #ands and teac# ot#er caregivers to ,as# #ands before contact ,it# patient and bet,een procedures ,it# patient7 !riction and r%nning )ater effecti+ely re&o+e &icroorganis&s fro& ands( Was ing bet)een $roced%res red%ces t e risk of
CC
trans&itting $at ogens fro& one area of t e body to anot er -e(g(' $erineal care or central line care.( Use of dis$osable glo+es does not red%ce t e need for and )as ing(
5imit visitors7 T is red%ces t e n%&ber of organis&s in $atient<s en+iron&ent and restricts +isitation by indi+id%als )it any ty$e of infection to red%ce t e trans&ission of $at ogens to t e $atient at risk for infection( T e &ost co&&on &odes of trans&ission are by direct contact -to%c ing. and by dro$let -airborne.(
$ncourage intake of protein+ and calorie+ric# foods7 T is &aintains o$ti&al n%tritional stat%s( $ncourage fluid intake of ;::: ml to >::: ml of ,ater per day (unless contraindicated)7 !l%ids $ro&ote dil%ted %rine and fre*%ent e&$tying of bladder; red%cing stasis of %rine' in t%rn' red%ces risk of bladder infection or %rinary tract infection -UTI.(
$ncourage coug#ing and deep breat#ing< consider use of incentive spirometer7 T ese &eas%res red%ce stasis of secretions in t e l%ngs and bronc ial tree( W en stasis occ%rs' $at ogens can ca%se %$$er res$iratory infections' incl%ding $ne%&onia(
Administer or teac# use of antimicrobial (antibiotic) drugs as ordered7 Anti&icrobial dr%gs incl%de antibacterial' antif%ngal' anti$arasitic' and anti+iral agents( All of t ese agents are eit er to#ic to t e $at ogen or retard t e $at ogen<s gro)t ( Ideally' t e selection of t e dr%g is based on c%lt%res fro& t e infected area; t is is often i&$ossible or i&$ractical' and in t ese cases' e&$irical &anage&ent %s%ally is %ndertaken )it a broad:s$ectr%& dr%g(
*lace patient in protective isolation if patient is at very #ig# risk7 4rotecti+e isolation is establis ed if ) ite blood cell co%nts indicate ne%tro$enia -H>11 to ;111 &&2.( Instit%tional $rotocols &ay +ary(
Recommend t#e use of soft+bristled toot#brus#es and stool softeners to protect mucous membranes7
"eac# patient or caregiver to ,as# #ands often, especially after toileting, before meals, and before and after administering self+care7 4atients and caregi+ers can s$read infection fro& one $art of t e body to anot er' as )ell as $ick %$ s%rface $at ogens; and )as ing red%ces t ese risks( CD
"eac# patient t#e importance of avoiding contact ,it# t#ose ,#o #ave infections or colds7 "eac# family members and caregivers about protecting susceptible patient from t#emselves and ot#ers ,it# infections or colds7 "eac# patient, family, and caregivers t#e purpose and proper tec#ni/ue for maintaining isolation7 "eac# patient to take antibiotics as prescribed7 6ost antibiotics )ork best ) en a constant blood le+el is &aintained; a constant blood le+el is &aintained ) en &edications are taken as $rescribed( T e absor$tion of so&e antibiotics is indered by certain foods; $atient s o%ld be instr%cted accordingly(
"eac# patient and caregiver t#e signs and symptoms of infection, and ,#en to report t#ese to t#e p#ysician or nurse7 Demonstrate and allo, return demonstration of all #ig#+risk procedures t#at patient or caregiver ,ill do after disc#arge, suc# as dressing c#anges, perip#eral or central %3 site care, peritoneal dialysis, self+cat#eteri1ation (may use clean tec#ni/ue)7 @ladder infection is &ore related to o+erdistended bladder res%lting fro& infre*%ent cat eteri7ation t an to %se of clean +ers%s sterile tec ni*%e(
I&$aired 4 ysical 6obility

I&&obility NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Ambulation 4alking Joint 2ovement Active 2obility 5evel
$!ercise "#erapy Ambulation
CE
Joint 2obility Fall *recautions *ositioning 'ed Rest Care
NANDA Definition: 5imitation in independent, purposeful p#ysical movement of t#e body or of one or more e!tremities Alteration in mobility may be a temporary or more permanent problem7 2ost disease and re#abilitative states involve some degree of immobility (e7g7, as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis)7 4it# t#e longer life e!pectancy for most Americans, t#e incidence of disease and disability continues to gro,7 And ,it# s#orter #ospital stays, patients are being transferred to re#abilitation facilities or sent #ome for p#ysical t#erapy in t#e #ome environment7 2obility is also related to body c#anges from aging7 5oss of muscle mass, reduction in muscle strengt# and function, stiffer and less mobile &oints, and gait c#anges affecting balance can significantly compromise t#e mobility of elderly patients7 2obility is paramount if elderly patients are to maintain any independent living7 Restricted movement affects t#e performance of most activities of daily living (AD5s)7 $lderly patients are also at increased risk for t#e complications of immobility7 .ursing goals are to maintain functional ability, prevent additional impairment of p#ysical activity, and ensure a safe environment7 Defining C aracteristics: %nability to move purposefully ,it#in p#ysical environment, including bed mobility, transfers, and ambulation, Reluctance to attempt movement, 5imited range of motion (R02), Decreased muscle endurance, strengt#, control, or mass, %mposed restrictions of movement including mec#anical, medical protocol, and impaired coordination, %nability to perform action as instructed Related !actors: Activity intolerance, *erceptual or cognitive impairment, 2usculoskeletal impairment, .euromuscular impairment, 2edical restrictions, *rolonged bed rest, 5imited strengt#, *ain or discomfort, Depression or severe an!iety
CF
"#$ected O%tco&es : *atient performs p#ysical activity independently or ,it# assistive devices as needed7 *atient is free of complications of immobility, as evidenced by intact skin, absence of t#rombop#lebitis, and normal bo,el pattern7 Ongoing Assess&ent
Assess for impediments to mobility (see Related Factors in t#is care plan)7 Identifying t e s$ecific ca%se -e(g(' c ronic art ritis +ers%s stroke +ers%s c ronic ne%rological disease. g%ides design of o$ti&al treat&ent $lan(
Assess patientBs ability to perform AD5s effectively and safely on a daily basis7 S%ggested Code for !%nctional 8e+el Classification : Completely independent 9 Re/uires use of e/uipment or device ; Re/uires #elp from anot#er person for assistance, supervision, or teac#ing > Re/uires #elp from anot#er person and e/uipment or device ? %s dependent, does not participate in activity Restricted &o+e&ent affects t e ability to $erfor& &ost AD8s( Safety )it a&b%lation is an i&$ortant concern(
Assess patient or caregiverBs kno,ledge of immobility and its implications7 "+en $atients ) o are te&$orarily i&&obile are at risk for effects of i&&obility s%c as skin breakdo)n' &%scle )eakness' t ro&bo$ lebitis' consti$ation' $ne%&onia' and de$ression(
Assess for developing t#rombop#lebitis (e7g7, calf pain, )omansB sign, redness, locali1ed s,elling, and rise in temperature)7 @ed rest or i&&obility $ro&ote clot for&ation( Assess skin integrity7 C#eck for signs of redness, tissue isc#emia (especially over ears, s#oulders, elbo,s, sacrum, #ips, #eels, ankles, and toes)7 2onitor input and output record and nutritional pattern7 Assess nutritional needs as t#ey relate to immobility (e7g7, possible #ypocalcemia, negative nitrogen balance)7 4ress%re sores de+elo$ &ore *%ickly in $atients )it a n%tritional deficit( 4ro$er n%trition also $ro+ides needed energy for $artici$ating in an e#ercise or re abilitati+e $rogra&(
D:
Assess elimination status (e7g7, usual pattern, present patterns, signs of constipation)7 I&&obility $ro&otes consti$ation( Assess emotional response to disability or limitation7 $valuate need for #ome assistance (e7g7, p#ysical t#erapy, visiting nurse)7 $valuate need for assistive devices7 4ro$er %se of ) eelc airs' canes' transfer bars' and ot er assistance can $ro&ote acti+ity and red%ce danger of falls( $valuate t#e safety of t#e immediate environment7 Obstacles s%c as t ro) r%gs' c ildren<s toys' and $ets can f%rt er i&$ede one<s ability to a&b%late safely(
$ncourage and facilitate early ambulation and ot#er AD5s ,#en possible7 Assist ,it# eac# initial c#ange dangling, sitting in c#air, ambulation7 T e longer t e $atient re&ains i&&obile t e greater t e le+el of debilitation t at )ill occ%r(
Facilitate transfer training by using appropriate assistance of persons or devices ,#en transferring patients to bed, c#air, or stretc#er7 $ncourage appropriate use of assistive devices in t#e #ome setting7 6obility aids can increase le+el of &obility( *rovide positive reinforcement during activity7 4atients &ay be rel%ctant to &o+e or initiate ne) acti+ity d%e to a fear of falling( Allo, patient to perform tasks at #is or #er o,n rate7 Do not rus# patient7 $ncourage independent activity as able and safe7 /os$ital )orkers and fa&ily caregi+ers are often in a %rry and do &ore for $atients t an needed' t ereby slo)ing t e $atient<s reco+ery and red%cing is or er self:estee&(
6eep side rails up and bed in lo, position7 T is $ro&otes a safe en+iron&ent( "urn and position every ; #ours or as needed7 T is o$ti&i7es circ%lation to all tiss%es and relie+es $ress%re( 2aintain limbs in functional alignment (e7g7, ,it# pillo,s, sandbags, ,edges, or prefabricated splints)7 T is $re+ents footdro$ and3or e#cessi+e $lantar fle#ion or tig#tness7 Support feet in dorsifle!ed position7 -se bed cradle7 T is kee$s ea+y bed linens off feet( D9
*erform passive or active assistive R02 e!ercises to all e!tremities7 "#ercise $ro&otes increased +eno%s ret%rn' $re+ents stiffness' and &aintains &%scle strengt and end%rance(
*romote resistance training services7 Researc s%$$orts t at strengt training and ot er for&s of e#ercise in older ad%lts can $reser+e t e ability to &aintain inde$endent li+ing stat%s and red%ce risk of falling(
"urn patient to prone or semiprone position once daily unless contraindicated7 T is drains bronc ial tree( -se prop#ylactic antipressure devices as appropriate7 T is $re+ents tiss%e breakdo)n( Clean, dry, and moisturi1e skin as needed7 $ncourage coug#ing and deep+breat#ing e!ercises7 T ese $re+ent b%ild%$ of secretions( -se suction as needed7 -se incentive spirometer7 T is increases l%ng e#$ansion( Decreased c est e#c%rsions and stasis of secretions are associated )it i&&obility(
$ncourage li/uid intake of ;::: to >::: ml/day unless contraindicated7 8i*%ids o$ti&i7e ydration stat%s and $re+ent ardening of stool( %nitiate supplemental #ig#+protein feedings as appropriate7 %f impairment results from obesity, initiate nutritional counseling as indicated7 4ro$er n%trition is re*%ired to &aintain ade*%ate energy le+el(
Set up a bo,el program (e7g7, ade/uate fluid, foods #ig# in bulk, p#ysical activity, stool softeners, la!atives) as needed7 Record bo,el activity level7 Administer medications as appropriate7 Antis$as&odic &edications &ay red%ce &%scle s$as&s or s$asticity t at interfere )it &obility( "eac# energy+saving tec#ni/ues7 T ese o$ti&i7e $atient<s li&ited reser+es( Assist patient in accepting limitations7 $mp#asi1e abilities7
D;
$!plain progressive activity to patient7 )elp patient or caregivers to establis# reasonable and obtainable goals7 %nstruct patient or caregivers regarding #a1ards of immobility7 $mp#asi1e importance of measures suc# as position c#ange, R02, coug#ing, and e!ercises7 Reinforce principles of progressive e!ercise, emp#asi1ing t#at &oints are to be e!ercised to t#e point of pain, not beyond7 ENo $ain' no gainE is not al)ays tr%eK %nstruct patient/family regarding need to make #ome environment safe7 A safe en+iron&ent is a $rere*%isite to i&$ro+ed &obility( Refer to multidisciplinary #ealt# team as appropriate7 4 ysical t era$ists can $ro+ide s$eciali7ed ser+ices( $ncourage verbali1ation of feelings, strengt#s, ,eaknesses, and concerns7
Nonco&$liance
Gno)ledge Deficit; 4atient "d%cation NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Ad#erence 'e#avior Compliance 'e#avior 6no,ledge "reatment Regimen *articipation )ealt# Care Decisions

'e#avior 2odification Decision+2aking Support *atient Contracting )ealt# $ducation
D>
NANDA Definition: 'e#avior of person and/or caregiver t#at fails to coincide ,it# a #ealt#+ promoting or t#erapeutic plan agreed on by t#e person (and/or family and/or community) and #ealt# care professional7 %n t#e presence of an agreed+on #ealt#+promoting or t#erapeutic plan, personBs or caregiverBs be#avior is fully or partially non+ad#erent and may lead to clinically ineffective or partially ineffective outcomes "#e fact t#at a patient #as attained kno,ledge regarding t#e treatment plan does not guarantee compliance7 Failure to follo, t#e prescribed plan may be related to a number of factors7 2uc# researc# #as been conducted in t#is area to identify key predictive factors7 Several t#eoretical models, suc# as t#e )ealt# 'elief 2odel, serve to e!plain t#ose factors t#at influence patient compliance7 *atients are more likely to comply ,#en t#ey believe t#at t#ey are susceptible to an illness or disease t#at could seriously affect t#eir #ealt#, t#at certain be#aviors ,ill reduce t#e likeli#ood of contracting t#e disease, and t#at t#e prescribed actions are less t#reatening t#an t#e disease itself7 Factors t#at may predict noncompliance include past #istory of noncompliance, stressful lifestyles, contrary cultural or religious beliefs and values, lack of social support, lack of financial resources, and compromised emotional state7 *eople living in adverse social situations (e7g7, battered ,omen, #omeless individuals, t#ose living amid street violence, t#e unemployed, or t#ose in poverty) may purposefully defer follo,ing medical recommendations until t#eir acute socioeconomic situation is improved7 "#e rising costs of #ealt# care, and t#e gro,ing number of uninsured and underinsured patients often forces patients ,it# limited incomes to c#oose bet,een food and medications7 "#e problem is especially comple! for elderly patients living on fi!ed incomes but re/uiring comple! and costly medical t#erapies7 Defining C aracteristics: 'e#avior indicative of failure to ad#ere, 0b&ective tests improper pill counts or missed prescription refills< body fluid analysis inconsistent ,it# compliance, $vidence of development of complications, $vidence of e!acerbation of symptoms, GRevolving+doorG #ospital admissions, 2issed appointments, "#erapeutic effect not ac#ieved or maintained Related !actors: *atientBs value system, )ealt# beliefs, Cultural beliefs, Spiritual values, Client+ provider relations#ips "#$ected O%tco&es: *atient and/or significant ot#er report compliance ,it# t#erapeutic plan7 *atient complies ,it# t#erapeutic plan, as evidenced by appropriate pill count, appropriate amount D?
of drug in blood or urine, evidence of t#erapeutic effect, maintained appointments, and/or fe,er #ospital admissions7 Ongoing Assess&ent
Assess patientBs individual perceptions of #ealt# problems7 According to t e /ealt @elief 6odel' a $atient<s $ercei+ed s%sce$tibility to and $ercei+ed serio%sness and t reat of disease affect co&$liance )it treat&ent $lan(
Assess beliefs about current illness7 Deter&ining ) at $atient t inks is ca%sing is or er sy&$to&s or disease' o) likely it is t at t e sy&$to&s &ay ret%rn' and any concerns abo%t t e diagnosis or sy&$to&s )ill $ro+ide a basis for $lanning f%t%re care( 4ersons of ot er c%lt%res and religio%s eritages &ay old differing +ie)s regarding ealt and illness( !or so&e c%lt%res t e ca%sati+e agent &ay be a $erson' not a &icrobe(
Assess religious beliefs or practices t#at affect #ealt#7 6any $eo$le +ie) illness as a $%nis &ent fro& God t at &%st be treated t ro%g s$irit%al ealing $ractices -e(g(' $rayer' $ilgri&age.' not &edications(
Assess beliefs about t#e treatment plan7 Understanding any )orries or &isconce$tions $atient &ay a+e abo%t t e $lan or side effects )ill g%ide f%t%re inter+entions( Determine reasons for noncompliance in t#e past7 S%c reasons &ay incl%de cogniti+e i&$air&ent' fear of act%ally e#$eriencing &edication side effects' fail%re to %nderstand instr%ctions regarding $lan -e(g(' diffic%lty %nderstanding a lo):sodi%& diet.' i&$aired &an%al de#terity -e(g(' not taking $ills beca%se %nable to o$en container.' sensory deficit -e(g(' %nable to read )ritten instr%ctions.' and disregard for nontraditional treat&ents -e(g(' erbs' lini&ents' $rayer' ac%$%nct%re.(
Determine cultural or spiritual influences on importance of #ealt# care7 Not all $ersons +ie) &aintenance of ealt t e sa&e( !or e#a&$le' so&e &ay $lace tr%st in God for treat&ent and ref%se $ills' blood transf%sions' or s%rgery( Ot ers &ay only )ant to follo) a Enat%ralE or E ealt foodE regi&en(
D=
Compare actual t#erapeutic effect ,it# e!pected effect7 4ro+ides infor&ation on co&$liance; o)e+er' if t era$y is ineffecti+e or based on a fa%lty diagnosis' e+en $erfect co&$liance )ill not res%lt in t e e#$ected t era$e%tic effect(
*lot pattern of #ospitali1ations and clinic appointments7 Ask patient to bring prescription drugs to appointment< count remaining pills7 T is $ro+ides so&e ob,ecti+e e+idence of co&$liance( Tec ni*%e is co&&only %sed in dr%g researc $rotocols(
Assess serum or urine drug level7 T era$e%tic blood le+els )ill not be ac ie+ed )it o%t consistent ingestion of &edication; o+erdosage or o+ertreat&ent can like)ise be assessed(
Develop a t#erapeutic relations#ip ,it# patient and family7 Co&$liance increases )it a tr%sting relations i$ )it a consistent caregi+er( Use of a skilled inter$reter is necessary for $atients not s$eaking t e do&inant lang%age(
%nclude patient in planning t#e treatment regimen7 4atients ) o beco&e co&anagers of t eir care a+e a greater stake in ac ie+ing a $ositi+e o%tco&e( Remove disincentives to compliance7 Actions s%c as decreasing )aiting ti&e in t e clinic' reco&&ending lo)er le+els of acti+ity' or s%ggesting &edications t at do not ca%se side effects t at are %nacce$table to $atient can i&$ro+e co&$liance(
Simplify t#erapy7 Suggest long+acting forms of medications and eliminate unnecessary medication7 $liminate unnecessary clinic visits7 Co&$liance increases ) en t era$y is as s ort and incl%des as fe) treat&ents as $ossible( T e $ ysical de&ands and financial b%rdens of tra+eling &%st be considered(
"ailor t#e t#erapy to patientBs lifestyle (e7g7, diuretics may be taken ,it# t#e evening meal for patients ,#o ,ork outside t#e #ome) and culture (incorporate #erbal medicinal massage or prayer, as appropriate)7
%ncrease t#e amount of supervision provided7 /o&e ealt n%rses' tele$ one &onitoring' and fre*%ent ret%rn +isits or a$$oint&ents can $ro+ide increased s%$er+ision( As compliance improves, gradually reduce t#e amount of professional supervision and reinforcement7 DC
Develop a be#avioral contract7 T is el$s $atient %nderstand and acce$t is or er role in t e $lan of care and clarifies ) at $atient can e#$ect fro& t e ealt care )orker or syste&(
Develop ,it# patient a system of re,ards t#at follo, successful compliance7 Re)ards $ro+ide $ositi+e reinforce&ent for co&$liant be a+ior(

*rovide specific instruction as indicated7 "ailor t#e information in terms of ,#at t#e patient feels is t#e cause of #is or #er #ealt# problem and #is or #er concerns about t#erapy7 "eac# significant ot#ers to eliminate disincentives and/or increase re,ards to patient for compliance7 $!plore community resources7 C %rc es' social cl%bs' and co&&%nity gro%$s can $lay a do&inant role in so&e c%lt%res( O%treac )orkers fro& a gi+en co&&%nity &ay effecti+ely ser+e as a bridge to t e ealt care $ro+ider(
*rovide social support t#roug# patientBs family and self+#elp groups7 S%c gro%$s &ay assist $atient in gaining greater %nderstanding of t e benefits of treat&ent(
I&balanced N%trition: 8ess t an @ody Re*%ire&ents

Star+ation; Weig t 8oss; Anore#ia NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

.utritional Status Food and Fluid %ntake .utritional Status .utrient %ntake

.utrition 2onitoring .utrition "#erapy
DD
.utrition 2anagement
NANDA Definition: %ntake of nutrients insufficient to meet metabolic needs Ade/uate nutrition is necessary to meet t#e bodyBs demands7 .utritional status can be affected by disease or in&ury states (e7g7, gastrointestinal @(%A malabsorption, cancer, burns)< p#ysical factors (e7g7, muscle ,eakness, poor dentition, activity intolerance, pain, substance abuse)< social factors (e7g7, lack of financial resources to obtain nutritious foods)< or psyc#ological factors (e7g7, depression, boredom)7 During times of illness (e7g7, trauma, surgery, sepsis, burns), ade/uate nutrition plays an important role in #ealing and recovery7 Cultural and religious factors strongly affect t#e food #abits of patients7 4omen e!#ibit a #ig#er incidence of voluntary restriction of food intake secondary to anore!ia, bulimia, and self+constructed fad dieting7 *atients ,#o are elderly like,ise e!perience problems in nutrition related to lack of financial resources, cognitive impairments causing t#em to forget to eat, p#ysical limitations t#at interfere ,it# preparing food, deterioration of t#eir sense of taste and smell, reduction of gastric secretion t#at accompanies aging and interferes ,it# digestion, and social isolation and boredom t#at cause a lack of interest in eating7 "#is care plan addresses general concerns related to nutritional deficits for t#e #ospital or #ome setting7 Defining C aracteristics: 5oss of ,eig#t ,it# or ,it#out ade/uate caloric intake, 9:H to ;:H belo, ideal body ,eig#t, Documented inade/uate caloric intake Related !actors: %nability to ingest foods, %nability to digest foods, %nability to absorb or metaboli1e foods, %nability to procure ade/uate amounts of food, 6no,ledge deficit, -n,illingness to eat, %ncreased metabolic needs caused by disease process or t#erapy "#$ected O%tco&es: *atient or caregiver verbali1es and demonstrates selection of foods or meals t#at ,ill ac#ieve a cessation of ,eig#t loss7 *atient ,eig#s ,it#in 9:H of ideal body ,eig#t7 Ongoing Assess&ent
Document actual ,eig#t< do not estimate7 4atients &ay be %na)are of t eir act%al )eig t or )eig t loss d%e to esti&ating )eig t(
DE
interv0btain nutritional #istory< include family, significant ot#ers, or caregiver in assessment7 4atient<s $erce$tion of act%al intake &ay differ( Determine etiological factors for reduced nutritional intake7 4ro$er assess&ent g%ides inter+ention( !or e#a&$le' $atients )it dentition $roble&s re*%ire referral to a dentist' ) ereas $atients )it &e&ory losses &ay re*%ire ser+ices s%c as 6eals:on: W eels(
2onitor or e!plore attitudes to,ard eating and food7 6any $syc ological' $syc osocial' and c%lt%ral factors deter&ine t e ty$e' a&o%nt' and a$$ro$riateness of food cons%&ed(
2onitor environment in ,#ic# eating occurs7 !e)er fa&ilies today a+e a general &eal toget er( 6any ad%lts find t e&sel+es Eeating on t e r%nE -e(g(' at t eir desk' in t e car. or relying ea+ily on fast foods )it red%ced n%tritional co&$onents(
$ncourage patient participation in recording food intake using a daily log7 Deter&ination of ty$e' a&o%nt' and $attern of food or fl%id intake is facilitated by acc%rate doc%&entation by $atient or caregi+er as t e intake occ%rs; &e&ory is ins%fficient(
2onitor laboratory values t#at indicate nutritional ,ell+being/deterioration serum albumin T is indicates degree of $rotein de$letion -0(> g3dl indicates se+ere de$letion; 2(B to A(> g3dl is nor&al.(
"ransferrin T is is i&$ortant for iron transfer and ty$ically decreases as ser%& $rotein decreases( R'C and 4'C counts T ese are %s%ally decreased in &aln%trition' indicating ane&ia and decreased resistance to infection( Serum electrolyte values 4otassi%& is ty$ically increased and sodi%& is ty$ically decreased in &aln%trition( 4eig# patient ,eekly7 D%ring aggressi+e n%tritional s%$$ort' $atient can gain %$ to 1(> $o%nd3day(
Consult dietitian for furt#er assessment and recommendations regarding food preferences and nutritional support7 Dietitians a+e a greater %nderstanding of t e n%tritional +al%e
DF
of foods and &ay be el$f%l in assessing s$ecific et nic or c%lt%ral foods -e(g(' Eso%l foods'E /is$anic dis es' kos er foods.(
$stablis# appropriate s#ort+ and long+range goals7 De$ending on t e etiological factors of t e $roble&' i&$ro+e&ent in n%tritional stat%s &ay take a long ti&e( Wit o%t realistic s ort:ter& goals to $ro+ide tangible re)ards' $atients &ay lose interest in addressing t is $roble&(
Suggest ,ays to assist patient ,it# meals as needed7 $nsure a pleasant environment, facilitate proper position, and provide good oral #ygiene and dentition7 "le+ating t e ead of bed 21 degrees aids in s)allo)ing and red%ces risk of as$iration(
*rovide companions#ip during mealtime7 Attention to t e social as$ects of eating is i&$ortant in bot t e os$ital and o&e settings( For patients ,it# c#anges in sense of taste, encourage use of seasoning7 For patients ,it# p#ysical impairments, refer to occupational t#erapist for adaptive devices7 For #ospitali1ed patients, encourage family to bring food from #ome as appropriate7 4atients )it s$ecific et nic' religio%s $references' or restrictions &ay not be able to eat os$ital foods(
Suggest li/uid drinks for supplemental nutrition7 Discourage beverages t#at are caffeinated or carbonated7 T ese &ay decrease a$$etite and lead to early satiety( Discuss possible need for enteral or parenteral nutritional support ,it# patient, family, and caregiver as appropriate7 "nteral t%be feedings are $referred for $atients )it a f%nctioning GI tract( !eedings &ay be contin%o%s or inter&ittent -bol%s.( 4arenteral n%trition &ay be indicated for $atients ) o cannot tolerate enteral feedings( "it er sol%tion can be &odified to $ro+ide re*%ired gl%cose' $rotein' electrolytes' +ita&ins' &inerals' and trace ele&ents( !at and fat:sol%ble +ita&ins can also be ad&inistered t)o or t ree ti&es $er )eek( T ese feedings &ay be %sed )it in: os$ital' long:ter& care' and s%bac%te care settings' as )ell as in t e o&e(
$ncourage e!ercise7 6etabolis& and %tili7ation of n%trients are en anced by acti+ity(
E:
Revie, and reinforce t#e follo,ing to patient or caregivers
"#e basic four food groups, as ,ell as t#e need for specific minerals or vitamins 4atients &ay not %nderstand ) at is in+ol+ed in a balanced diet( %mportance of maintaining ade/uate caloric intake< an average adult (D: kg) needs 9E:: to ;;:: kcal/ day< patients ,it# burns, severe infections, or draining ,ounds may re/uire >::: to ?::: kcal/day Foods #ig# in calories and protein t#at ,ill promote ,eig#t gain and nitrogen balance (e7g7, small fre/uent meals of foods #ig# in calories and protein)
*rovide referral to community nutritional resources suc# as 2eals+on+4#eels or #ot lunc# programs for seniors as indicated7
I&balanced N%trition: 6ore t an @ody Re*%ire&ents

Obesity; O+er)eig t NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

.utritional Status Food and Fluid %ntake 4eig#t Control

.utritional 2onitoring .utrition Counseling 4eig#t Reduction Assistance E9
NANDA Definition: %ntake of nutrients t#at e!ceeds metabolic needs 0besity is a common problem in t#e -nited States and accounts for significant ot#er #ealt# problems including cardiovascular disease, insulin dependent diabetes, sleep disorders, infertility in ,omen, aggravated musculoskeletal problems, and s#ortened life e!pectancy7 4omen are more likely to be over,eig#t t#an men7 African Americans and )ispanic individuals are more likely to be over,eig#t t#an Caucasians7 Factors t#at affect ,eig#t gain include genetics, sedentary lifestyle, emotional factors associated ,it# dysfunctional eating, disease states suc# as diabetes mellitus and Cus#ingBs syndrome, and cultural or et#nic influences on eating7 0verall nutritional re/uirements of elderly patients are similar to t#ose of younger individuals, e!cept calories s#ould be reduced because of t#eir leaner body mass7 Defining C aracteristics: 4eig#t ;:H over ideal for #eig#t and frame, "riceps skinfold greater t#an 9= mm in men, ;= mm in ,omen, Reported or observed dysfunctional eating patterns, $ating in response to internal cues ot#er t#an #unger, $ating in response to e!ternal cues suc# as time of day or social situation Related !actors: $!cessive intake in relation to metabolic need, 5ack of kno,ledge of nutritional needs, food intake, and/or appropriate food preparation, *oor dietary #abits, -se of food as coping mec#anism, 2etabolic disorders, Sedentary activity level "#$ected O%tco&es *atient verbali1es measures necessary to ac#ieve ,eig#t reduction7 *atient demonstrates appropriate selection of meals or menu planning to,ard t#e goal of ,eig#t reduction7 *atient begins an appropriate program of e!ercise7 Ongoing Assess&ent

Document ,eig#t< do not estimate7 4atients &ay be %na)are of t eir act%al )eig t( Determine body fat composition by skinfold measurements7 Skin cali$ers can be %sed to esti&ate a&o%nt of fat( Calculate body mass inde! as a ratio of #eig#t and ,eig#t7 @ody &ass inde# -@6I. is t e $erson<s )eig t in kilogra&s di+ided by t e s*%are of is or er eig t in &eters( A
E;
@6I bet)een 01 and 0A is associated )it
ealt ier o%tco&es( @6Is greater t an 0>
are associated )it increased &orbidity and &ortality( *erform a nutritional assessment7 T is incl%des ty$es and a&o%nt of food' o) food is $re$ared' intake $attern -e(g(' ti&e of day' fre*%ency' ot er acti+ities $atient does ) ile eating.(
$!plore t#e importance and meaning of food ,it# t#e patient7 W en food is %sed as a co$ing &ec anis& or as a self:re)ard' t e e&otional needs being &et by intake of food )ill need to be addressed as $art of t e o+erall $lan for )eig t red%ction( In &ost c%lt%res' eating is a social acti+ity(
Assess kno,ledge regarding nutritional needs for #eig#t and level of activity or ot#er factors (e7g7, pregnancy)7 Assess ability to read food labels7 !ood labels contain infor&ation necessary in &aking a$$ro$riate selections' b%t can be &isleading( 4atients need to %nderstand t at Elo): fatE or Efat:freeE does not &ean t at a food ite& is calorie:free(
Assess ability to plan a menu, making appropriate food selections7 C%lt%ral or et nic infl%ences need to be identified and addressed( Assess ability to accurately identify appropriate food portions7 Ser+ing si7es &%st be %nderstood to li&it intake according to a $lanned diet( Assess effects or complications of being over,eig#t7 6edical co&$lications incl%de cardio+asc%lar and res$iratory dysf%nction' ig er incidence of diabetes &ellit%s' and aggra+ation of &%sc%loskeletal disorders( Social co&$lications and $oor self:estee& &ay also res%lt fro& obesity(
Assess usual level of activity7 4atients &ay conf%se ro%tine acti+ity )it e#ercise necessary to en ance and &aintain )eig t loss(
Consult dietitian for furt#er assessment and recommendations regarding a ,eig#t loss program7 C anges in eating $atterns are re*%ired for )eig t loss( T e ty$e of $rogra& &ay +ary -e(g(' t ree balanced &eals a day' a+oidance of certain ig :fat foods.( Dietitians a+e a greater %nderstanding of t e n%tritional +al%e of foods and &ay be el$f%l in assessing or s%bstit%ting s$ecific ig :fat c%lt%ral or et nic foods( E>
$stablis# appropriate s#ort+ and long+range goals7 One $o%nd of adi$ose tiss%e contains 2>11 kcal( T erefore to lose ; $o%nd3)eek' t e $atient &%st a+e a calorie deficit of >11 kcal3day(
$ncourage calorie intake appropriate for body type and lifestyle7 Diet c ange is a co&$licated $rocess t at in+ol+es c anging $atterns t at a+e been fir&ly establis ed by c%lt%re' fa&ily' and $ersonal factors(
$ncourage patient to keep a daily log of food or li/uid ingestion and caloric intake7 6e&ory is inade*%ate for *%antification of intake' and a +is%al record &ay also el$ $atient to &ake &ore a$$ro$riate food c oices and ser+ing si7es(
$ncourage ,ater intake7 Water assists in t e e#cretion of by$rod%cts of fat breakdo)n and el$s $re+ent ketosis( $ncourage patient to be more a,are of nutritional #abits t#at may contribute to or prevent overeating "o reali1e t#e time needed for eating7 /%rried eating &ay res%lt in o+ereating beca%se satiety is not reali7ed %ntil ;> to 01 &in%tes after ingestion of food( "o focus on eating and to avoid ot#er diversional activities (e7g7, reading, television vie,ing, or telep#oning)7 "o observe for cues t#at lead to eating (e7g7, odor, time, depression, or boredom)7 "o eat in a designated place (e7g7, at t#e table rat#er t#an in front of t#e television)7 T is controls en+iron&ental sti&%li for eating and ot er i&$%lse eating(
"o recogni1e actual #unger versus desire to eat7 "ating ) en not %ngry is a co&&only recogni7ed sy&$to& a&ong o+ereaters( $ncourage e!ercise7 "#ercise is an integral $art of )eig t red%ction $rogra&s( T e co&bination of diet and e#ercise $ro&otes loss of adi$ose tiss%e rat er t an lean tiss%e(
*rovide positive reinforcement as indicated7 $ncourage successes< assist patient to cope ,it# setbacks7 %ncorporate be#avior modification strategies7 "d%cation as t e sole inter+ention is %nlikely to ac ie+e and &aintain )eig t loss( 6%ltifactorial $rogra&s t at incl%de be a+ioral inter+entions and co%nseling are &ore s%ccessf%l t an ed%cation alone(
E?
Revie, and reinforce teac#ing regarding t#e follo,ing

Four food groups or t#e food pyramid *roper serving si1es Caloric content of food 6any $atients are %na)are of t e calories $resent in lo):fat foods( 2et#ods of preparation, suc# as substituting baking and grilling for frying foods
%nclude family, caregiver, or food preparer in t#e nutrition counseling7 S%ccess rates are ig er ) en t e fa&ily incor$orates a ealt y eating $lan( %nform patient about p#armacological agents suc# as appetite suppressants t#at can aid in ,eig#t loss7 T ese dr%gs act by c e&ically altering t e $atient<s desire to eat( $ncourage diabetic patients to attend diabetic classes7 Revie, and reinforce principles of dietary management of diabetes7 Obesity and diabetes are risk factors for coronary artery disease(
Revie, complications associated ,it# obesity7 Refer patient to commercial ,eig#t+loss program as appropriate7 So&e indi+id%als re*%ire t e regi&ented a$$roac or ongoing s%$$ort d%ring )eig t loss' ) ereas ot ers are able -and &ay $refer. to &anage a )eig t:loss $rogra& inde$endently(
Remind patient t#at significant ,eig#t loss re/uires a long period7 Refer to community support groups as indicated7
E=
Ac%te 4ain

Comfort 5evel 2edication Response *ain Control

Analgesic Administration Conscious Sedation *ain 2anagement *atient+Controlled Analgesia Assistance
NANDA Definition: -npleasant sensory and emotional e!perience arising from actual or potential tissue damage or described in terms of suc# damage (%nternational Association for t#e Study of *ain)< sudden or slo, onset of any intensity from mild to severe ,it# an anticipated or predictable end and a duration of less t#an C mont#s *ain is a #ig#ly sub&ective state in ,#ic# a variety of unpleasant sensations and a ,ide range of distressing factors may be e!perienced by t#e sufferer7 *ain may be a symptom of in&ury or illness7 *ain may also arise from emotional, psyc#ological, cultural, or spiritual distress7 *ain can be very difficult to e!plain, because it is uni/ue to t#e individual< pain s#ould be accepted as described by t#e sufferer7 *ain assessment can be c#allenging, especially in elderly patients, ,#ere cognitive impairment and sensory+perceptual deficits are more common7 Defining C aracteristics *atient reports pain, (uarding be#avior, protecting body part, Self+ focused, .arro,ed focus (e7g7, altered time perception, ,it#dra,al from social or p#ysical
EC
contact), Relief or distraction be#avior (e7g7, moaning, crying, pacing, seeking out ot#er people or activities, restlessness), Facial mask of pain, Alteration in muscle tone listlessness or flaccidness< rigidity or tension, Autonomic responses (e7g7, diap#oresis< c#ange in blood pressure @'*A, pulse rate< pupillary dilation< c#ange in respiratory rate< pallor< nausea) Related !actors *ostoperative pain, Cardiovascular pain, 2usculoskeletal pain, 0bstetrical pain, *ain resulting from medical problems, *ain resulting from diagnostic procedures or medical treatments, *ain resulting from trauma, *ain resulting from emotional, psyc#ological, spiritual, or cultural distress "#$ected O%tco&es: *atient verbali1es ade/uate relief of pain or ability to cope ,it# incompletely relieved pain7 Ongoing Assess&ent
Assess pain c#aracteristics

Iuality (e7g7, s#arp, burning, s#ooting) Severity (scale of 9 to 9:, ,it# 9: being t#e most severe) Ot er &et ods s%c as a +is%al analog scale or descri$ti+e scales can be %sed to identify e#tent of $ain( 5ocation (anatomical description) 0nset (gradual or sudden) Duration (#o, long< intermittent or continuous) *recipitating or relieving factors
0bserve or monitor signs and symptoms associated ,it# pain, suc# as '*, #eart rate, temperature, color and moisture of skin, restlessness, and ability to focus7 So&e $eo$le deny t e e#$erience of $ain ) en it is $resent( Attention to associated signs &ay el$ t e n%rse in e+al%ating $ain(
Assess for probable cause of pain7 Different etiological factors res$ond better to different t era$ies( Assess patientBs kno,ledge of or preference for t#e array of pain+relief strategies available7 So&e $atients &ay be %na)are of t e effecti+eness of non$ ar&acological &et ods
ED
and &ay be )illing to try t e&' eit er )it or instead of traditional analgesic &edications( Often a co&bination of t era$ies -e(g(' &ild analgesics )it distraction or eat. &ay $ro+e &ost effecti+e(
$valuate patientBs response to pain and medications or t#erapeutics aimed at abolis#ing or relieving pain7 It is i&$ortant to el$ $atients e#$ress as fact%ally as $ossible -i(e(' )it o%t t e effect of &ood' e&otion' or an#iety. t e effect of $ain relief &eas%res( Discre$ancies bet)een be a+ior or a$$earance and ) at $atient says abo%t $ain relief -or lack of it. &ay be &ore a reflection of ot er &et ods $atient is %sing to co$e )it t an $ain relief itself(
Assess to ,#at degree cultural, environmental, intrapersonal, and intrapsyc#ic factors may contribute to pain or pain relief7 T ese +ariables &ay &odify t e $atient<s e#$ression of is or er e#$erience( !or e#a&$le' so&e c%lt%res o$enly e#$ress feelings' ) ile ot ers restrain s%c e#$ression( /o)e+er' ealt care $ro+iders s o%ld not stereoty$e any $atient res$onse b%t rat er e+al%ate t e %ni*%e res$onse of eac $atient(
$valuate ,#at t#e pain means to t#e individual7 T e &eaning of t e $ain )ill directly infl%ence t e $atient<s res$onse( So&e $atients' es$ecially t e dying' &ay feel t at t e Eact of s%fferingE &eets a s$irit%al need(
Assess patientBs e!pectations for pain relief7 So&e $atients &ay be content to a+e $ain decreased; ot ers )ill e#$ect co&$lete eli&ination of $ain( T is affects t eir $erce$tions of t e effecti+eness of t e treat&ent &odality and t eir )illingness to $artici$ate in additional treat&ents(
Assess patientBs ,illingness or ability to e!plore a range of tec#ni/ues aimed at controlling pain7 So&e $atients )ill feel %nco&fortable e#$loring alternati+e &et ods of $ain relief( /o)e+er' $atients need to be infor&ed t at t ere are &%lti$le )ays to &anage $ain(
Assess appropriateness of patient as a patient+controlled analgesia (*CA) candidate no #istory of substance abuse< no allergy to narcotic analgesics< clear sensorium< cooperative and motivated about use< no #istory of renal, #epatic, or respiratory disease< manual de!terity< and no #istory of ma&or psyc#iatric disorder7 4CA is t e intra+eno%s -I5. inf%sion of a narcotic -%s%ally &or$ ine or De&erol. t ro%g an inf%sion $%&$ t at is controlled by t e $atient( T is allo)s t e $atient to &anage $ain relief )it in
EE
$rescribed li&its( In t e os$ice or o&e setting' a n%rse or caregi+er &ay be needed to assist t e $atient in &anaging t e inf%sion(
2onitor for c#anges in general condition t#at may #erald need for c#ange in pain relief met#od7 !or e#a&$le' a 4CA $atient beco&es conf%sed and cannot &anage 4CA' or a s%ccessf%l &odality ceases to $ro+ide ade*%ate $ain relief' as in rela#ation breat ing(
%f patient is on *CA, assess t#e follo,ing *ain relief T e basal or lock:o%t dose &ay need to be increased to co+er t e $atient<s $ain( %ntactness of %3 line If t e I5 is not $atent' $atient )ill not recei+e $ain &edication( Amount of pain medication patient is re/uesting If de&ands for &edication are *%ite fre*%ent' $atient<s dosage &ay need to be increased( If de&ands are +ery lo)' $atient &ay re*%ire f%rt er instr%ction to $ro$erly %se 4CA(
*ossible *CA complications suc# as e!cessive sedation, respiratory distress, urinary retention, nausea/vomiting, constipation, and %3 site pain, redness, or s,elling 4atients &ay also e#$erience &ild allergic res$onse to t e analgesic agent' &arked by generali7ed itc ing or na%sea and +o&iting(
%f patient is receiving epidural analgesia, assess t#e follo,ing
*ain relief Inter&ittent e$id%rals re*%ire redosing at inter+als( 5ariations in anato&y &ay res%lt in a E$atc effect(E .umbness, tingling in e!tremities, a metallic taste in t#e mout# T ese sy&$to&s &ay be indicators of an allergic res$onse to t e anest esia agent' or of i&$ro$er cat eter $lace&ent(
*ossible epidural analgesia complications suc# as e!cessive sedation, respiratory distress, urinary retention, or cat#eter migration Res$iratory de$ression and intra+asc%lar inf%sion of anest esia -res%lting fro& cat eter &igration. can be $otentially life: t reatening(
EF
Anticipate need for pain relief7 One can &ost effecti+ely deal )it $ain by $re+enting it( "arly inter+ention &ay decrease t e total a&o%nt of analgesic re*%ired( Respond immediately to complaint of pain7 In t e &idst of $ainf%l e#$eriences a $atient<s $erce$tion of ti&e &ay beco&e distorted( 4ro&$t res$onses to co&$laints &ay res%lt in decreased an#iety in t e $atient( De&onstrated concern for $atient<s )elfare and co&fort fosters t e de+elo$&ent of a tr%sting relations i$(
$liminate additional stressors or sources of discomfort ,#enever possible7 4atients &ay e#$erience an e#aggeration in $ain or a decreased ability to tolerate $ainf%l sti&%li if en+iron&ental' intra$ersonal' or intra$syc ic factors are f%rt er stressing t e&(
*rovide rest periods to facilitate comfort, sleep, and rela!ation7 T e $atient<s e#$eriences of $ain &ay beco&e e#aggerated as t e res%lt of fatig%e( In a cyclic fas ion' $ain &ay res%lt in fatig%e' ) ic &ay res%lt in e#aggerated $ain and e# a%stion( A *%iet en+iron&ent' a darkened roo&' and a disconnected $ one are all &eas%res geared to)ard facilitating rest(
Determine t#e appropriate pain relief met#od7 *#armacological met#ods include t#e follo,ing %7 %%7 .onsteroidal antiinflammatory drugs (.SA%Ds) t#at may be administered orally or parenterally (to date, ketorolac is t#e only available parenteral .SA%D)7 -se of opiates t#at may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient+controlled analgesia (*CA) systems, or epidurally (eit#er by bolus or continuous infusion)7 Narcotics are indicated for se+ere $ain' es$ecially in t e os$ice or o&e setting( %%%7 5ocal anest#etic agents7 .onp#armacological met#ods include t#e follo,ing %37 Cognitive+be#avioral strategies as follo,s
%magery T e %se of a &ental $ict%re or an i&agined e+ent in+ol+es %se of t e fi+e senses to distract oneself fro& $ainf%l sti&%li( F:
Distraction tec#ni/ues /eig ten one<s concentration %$on non$ainf%l sti&%li to decrease one<s a)areness and e#$erience of $ain( So&e &et ods are breat ing &odifications and ner+e sti&%lation( Rela!ation e!ercises Tec ni*%es are %sed to bring abo%t a state of $ ysical and &ental a)areness and tran*%ility( T e goal of t ese tec ni*%es is to red%ce tension' s%bse*%ently red%cing $ain( 'iofeedback, breat#ing e!ercises, music t#erapy 2assage of affected area ,#en appropriate 6assage decreases &%scle tension and can $ro&ote co&fort( "ranscutaneous electrical nerve stimulation ("$.S) units )ot or cold compress /ot' &oist co&$resses a+e a $enetrating effect( T e )ar&t r%s es blood to t e affected area to $ro&ote ealing( Cold co&$resses &ay red%ce total ede&a and $ro&ote so&e n%&bing' t ereby $ro&oting co&fort(
37
Cutaneous stimulation as follo,s
(ive analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of unto,ard effects7 4ain &edications are absorbed and &etaboli7ed differently by $atients' so t eir effecti+eness &%st be e+al%ated fro& $atient to $atient( Analgesics &ay ca%se side effects t at range fro& &ild to life:t reatening(
.otify p#ysician if interventions are unsuccessful or if current complaint is a significant c#ange from patientBs past e!perience of pain7 4atients ) o re*%est $ain &edications at &ore fre*%ent inter+als t an $rescribed &ay act%ally re*%ire ig er doses or &ore $otent analgesics(
4#enever possible, reassure patient t#at pain is time+limited and t#at t#ere is more t#an one approac# to easing pain7 W en $ain is $ercei+ed as e+erlasting and %nresol+able' $atient &ay gi+e %$ trying to co$e )it or e#$erience a sense of o$elessness and loss of control( If $atient is on 4CA:
Dedicate use of %3 line for *CA only< consult p#armacist before mi!ing drug ,it# narcotic being infused7 I5 inco&$atibilities are $ossible( F9
If $atient is recei+ing e$id%ral analgesia:
5abel all tubing (e7g7, epidural cat#eter, %3 tubing to epidural cat#eter) clearly to prevent inadvertent administration of inappropriate fluids or drugs into epidural space7 !or $atients )it 4CA or e$id%ral analgesia:
6eep .arcan or ot#er narcotic+reversing agent readily available7 In t e e+ent of res$iratory de$ression' t ese dr%gs re+erse t e narcotic effect( *ost G.o additional analgesiaG sign over bed7 T is $re+ents inad+ertent analgesic o+erdosing(
*rovide anticipatory instruction on pain causes, appropriate prevention, and relief measures7 $!plain cause of pain or discomfort, if kno,n7 %nstruct patient to report pain7 Relief &eas%res &ay be instit%ted( %nstruct patient to evaluate and report effectiveness of measures used7 "eac# patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods7 !or $atients on 4CA or t ose recei+ing e$id%ral analgesia:
"eac# patient preoperatively7 Anest esia effects s o%ld not obsc%re teac ing( "eac# patient t#e purpose, benefits, tec#ni/ues of use/action, need for %3 line (*CA only), ot#er alternatives for pain control, and of t#e need to notify nurse of mac#ine alarm and occurrence of unto,ard effects7
F;
C ronic 4ain

*ain Control Iuality of 5ife Family Coping

*ain 2anagement 2edication 2anagement Acupressure )eat/Cold Application *rogressive 2uscle Rela!ation "ranscutaneous $lectrical .erve Stimulation ("$.S) Simple 2assage
NANDA Definition: -npleasant sensory and emotional e!perience arising from actual or potential tissue damage or described in terms of suc# damage (%nternational Association for t#e Study of *ain)< sudden or slo, onset of intensity from mild to severe< constant or recurring ,it#out an anticipated or predictable end and a duration of greater t#an C mont#s
F>
C#ronic pain may be classified as c#ronic malignant pain or c#ronic nonmalignant pain7 %n t#e former, t#e pain is associated ,it# a specific cause suc# as cancer7 4it# c#ronic nonmalignant pain t#e original tissue in&ury is not progressive or #as been #ealed7 %dentifying an organic cause for t#is type of c#ronic pain is more difficult7 C#ronic pain differs from acute pain in t#at it is #arder for t#e patient to provide specific information about t#e location and t#e intensity of t#e pain7 0ver time it becomes more difficult for t#e patient to differentiate t#e e!act location of t#e pain and clearly identify t#e intensity of t#e pain7 "#e patient ,it# c#ronic pain often does not present ,it# be#aviors and p#ysiological c#anges associated ,it# acute pain7 Family members, friends, co,orkers, employers, and #ealt# care providers /uestion t#e legitimacy of t#e patientBs pain complaints because t#e patient may not look like someone in pain7 "#e patient may be accused of using pain to gain attention or to avoid ,ork and family responsibilities7 4it# c#ronic pain, t#e patientBs level of suffering usually increases over time7 C#ronic pain can #ave a profound impact on t#e patientBs activities of daily living, mobility, activity tolerance, ability to ,ork, role performance, financial status, mood, emotional status, spirituality, family interactions, and social interactions7 Defining C aracteristics: 4eig#t c#anges, 3erbal or coded report or observed evidence of protective be#avior, guarding be#avior, facial mask, irritability, self+focusing, restlessness, depression, Atrop#y of involved muscle group, C#anges in sleep pattern, Fatigue, Fear of rein&ury, Reduced interaction ,it# people, Altered ability to continue previous activities, Sympat#etic mediated responses (e7g7, temperature, cold, c#anges of body position, #ypersensitivity), Anore!ia Related !actors: C#ronic p#ysical or psyc#osocial disability "#$ected O%tco&es : *atient verbali1es acceptable level of pain relief and ability to engage in desired activities7 Ongoing Assess&ent
Assess pain c#aracteristics
Iuality (e7g7, s#arp, burning)
F?
Severity (9 to 9: scale) Anatomical location 0nset Duration (e7g7, continuous, intermittent) Aggravating factors Relieving factors
Gat ering infor&ation abo%t t e $ain can $ro+ide infor&ation abo%t t e e#tent of t e c ronic $ain(
Assess for signs and symptoms associated ,it# c#ronic pain suc# as fatigue, decreased appetite, ,eig#t loss, c#anges in body posture, sleep pattern disturbance, an!iety, irritability, restlessness, or depression7 4atients )it c ronic $ain &ay not e# ibit t e $ ysiological c anges and be a+iors associated )it ac%te $ain( 4%lse and blood $ress%re are %s%ally )it in nor&al ranges( T e g%arding be a+ior of ac%te $ain &ay beco&e a $ersistent c ange in body $ost%re for t e $atient )it c ronic $ain( Co$ing )it c ronic $ain can de$lete t e $atient<s energy for ot er acti+ities( T e $atient often looks tired )it a dra)n facial e#$ression t at lacks ani&ation(
Assess t#e patientBs perception of t#e effectiveness of met#ods used for pain relief in t#e past7 4atients )it c ronic $ain a+e a long istory of %sing &any $ ar&acological and non$ ar&acological &et ods to control t eir $ain(
$valuate gender, cultural, societal, and religious factors t#at may influence t#e patientBs pain e!perience and response to pain relief7 Understanding t e +ariables t at affect t e $atient<s $ain e#$erience can be %sef%l in de+elo$ing a $lan of care t at is acce$table to t e $atient(
Assess t#e patientBs e!pectations about pain relief7 T e $atient )it c ronic $ain &ay not e#$ect co&$lete absence of $ain' b%t &ay be satisfied )it decreasing t e se+erity of t e $ain and increasing acti+ity le+el(
Assess t#e patientBs attitudes to,ard p#armacological and nonp#armacological met#ods of pain management7 4atients &ay *%estion t e effecti+eness of non$ ar&acological inter+entions and see &edications as t e only treat&ent for $ain(
F=
For patients taking opioid analgesics, assess for side effects, dependency, and tolerance7 Dr%g de$endence and tolerance to o$ioid analgesics is a concern in t e long:ter& &anage&ent of c ronic $ain(
Assess t#e patientBs ability to accomplis# activities of daily living (AD5s), instrumental activities of daily living (%AD5s), and demands of daily living (DD5s)7 !atig%e' an#iety' and de$ression associated )it c ronic $ain can li&it t e $erson<s ability to co&$lete self:care acti+ities and f%lfill role res$onsibilities(
$ncourage t#e patient to keep a pain diary to #elp in identifying aggravating and relieving factors of c#ronic pain7 Gno)ledge abo%t factors t at infl%ence t e $ain e#$erience can g%ide t e $atient in &aking decisions abo%t lifestyle &odifications t at $ro&ote &ore effecti+e $ain &anage&ent(
Ackno,ledge and convey acceptance of t#e patientBs pain e!perience7 T e $atient &ay a+e ad negati+e e#$eriences in t e $ast )it attit%des of ealt care $ro+iders to)ard t e $atient<s $ain e#$erience( Con+eying acce$tance of t e $atient<s $ain $ro&otes a &ore coo$erati+e n%rse:$atient relations i$(
*rovide t#e patient and family ,it# information about c#ronic pain and options available for pain management7 8ack of kno)ledge abo%t t e c aracteristics of c ronic $ain and $ain &anage&ent strategies can add to t e b%rden of $ain in t e $atient<s life(
Assist t#e patient in making decisions about selecting a particular pain management strategy7 G%idance and s%$$ort fro& t e n%rse can increase t e $atient<s )illingness to c oose ne) inter+entions to $ro&ote $ain relief( T e $atient &ay begin to feel confident abo%t t e effecti+eness of t ese inter+entions(
Refer t#e patient to a p#ysical t#erapist for evaluation7 T e $ ysical t era$ist can el$ t e $atient )it e#ercises to $ro&ote &%scle strengt and ,oint &obility' and t era$ies to $ro&ote rela#ation of tense &%scles( T ese inter+entions can contrib%te to effecti+e $ain &anage&ent(
FC
"eac# t#e patient and family about using nonp#armacological pain management strategies
Cold applications Cold red%ces $ain' infla&&ation' and &%scle s$asticity by decreasing t e release of $ain:ind%cing c e&icals and slo)ing t e cond%ction of $ain i&$%lses( T is inter+ention re*%ires no s$ecial e*%i$&ent and can be cost effecti+e( Cold a$$lications s o%ld last abo%t 01 to 21 &in3 r( )eat applications /eat red%ces $ain t ro%g i&$ro+ed blood flo) to t e area and t ro%g red%ction of $ain refle#es( T is is a cost:effecti+e inter+ention t at re*%ires no s$ecial e*%i$&ent( /eat a$$lications s o%ld last no &ore t an 01 &in3 r( S$ecial attention needs to be gi+en to $re+enting b%rns )it t is inter+ention( 2assage of t#e painful area 6assage interr%$ts $ain trans&ission' increases endor$ in le+els' and decreases tiss%e ede&a( T is inter+ention &ay re*%ire anot er $erson to $ro+ide t e &assage( 6any ealt ins%rance $rogra&s )ill not rei&b%rse for t e cost of t era$e%tic &assage( *rogressive rela!ation, imagery, and music T ese centrally acting tec ni*%es for $ain &anage&ent )ork t ro%g red%cing &%scle tension and stress( T e $atient &ay feel an increased sense of control o+er is3 er $ain( G%ided i&agery can el$ t e $atient e#$lore i&ages abo%t $ain' $ain relief' and ealing( T ese tec ni*%es re*%ire $ractice to be effecti+e( Distraction Distraction is a te&$orary $ain &anage&ent strategy t at )orks by increasing t e $ain t res old( It s o%ld be %sed for a s ort d%ration' %s%ally less t an 0 o%rs at a ti&e( 4rolonged %se can add to fatig%e and increased $ain ) en t e distraction is no longer $resent( Acupressure Ac%$ress%re in+ol+es finger $ress%re a$$lied to ac%$ress%re $oints on t e body( Using t e gate control t eory' t e tec ni*%e )orks to interr%$t $ain trans&ission by Eclosing t e gate(E T is a$$roac re*%ires training and $ractice(
FD
"ranscutaneous $lectrical .erve Stimulation ("$.S) T"NS re*%ires t e a$$lication of 0 to A skin electrodes( 4ain red%ction occ%rs t ro%g a &ild electrical c%rrent( T e $atient is able to reg%late t e intensity and fre*%ency of t e electrical sti&%lation( Gno)ledge abo%t o) to i&$le&ent non$ ar&acological $ain &anage&ent strategies can el$ t e $atient and fa&ily gain &a#i&%& benefit fro& t ese inter+entions(
"eac# t#e patient and family about t#e use of p#armacological interventions for pain management
.onsteroidal antiinflammatory agents (.SA%Ds) T ese dr%gs are t e first ste$ in an analgesic ladder( T ey )ork in $eri$ eral tiss%es by in ibiting t e synt esis of $rostaglandins t at ca%se $ain' infla&&ation' and ede&a( T e ad+antages of t ese dr%gs are t ey can be taken orally and are not associated )it de$endency and addiction( 0pioid analgesics T ese dr%gs act on t e central ner+o%s syste& to red%ce $ain by binding )it o$iate rece$tors t ro%g o%t t e body( T e side effects associated )it t is gro%$ of dr%gs tend to be &ore significant t at t ose )it t e NSAIDs( Na%sea' +o&iting' consti$ation' sedation' res$iratory de$ression' tolerance' and de$endency are of concern in $atients %sing t ese dr%gs for c ronic $ain &anage&ent( Anti+depressants T ese dr%gs &ay be %sef%l ad,%ncts in a total $rogra& of $ain &anage&ent( In addition to t eir effects on t e $atient<s &ood' t e antide$ressants &ay a+e analgesic $ro$erties a$art fro& t eir antide$ressant actions( Antian!iety agents T ese dr%gs &ay be %sef%l ad,%ncts in a total $rogra& of $ain &anage&ent( In addition to t eir effects on t e $atient<s &ood' t e antide$ressants &ay a+e analgesic $ro$erties a$art fro& t eir antide$ressant actions(
Assist t#e patient and family in identifying lifestyle modifications t#at may contribute to effective pain management7 C anges in )ork ro%tines' o%se old res$onsibilities' and t e o&e $ ysical en+iron&ent &ay be needed to $ro&ote &ore effecti+e $ain
FE
&anage&ent( 4ro+iding t e $atient and fa&ily )it ongoing s%$$ort and g%idance )ill increase t e s%ccess of t ese strategies(
Refer t#e patient and family to community support groups and self+#elp groups for people coping ,it# c#ronic pain7 Adding to t e $atient<s net)ork of social s%$$ort can red%ce t e b%rden of s%ffering associated )it c ronic $ain and $ro+ide additional reso%rces(
Self:Care Deficit
@at ing3/ygiene; Dressing3Groo&ing; !eeding; Toileting NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Self+Care $ating Self+Care 'at#ing Self+Care Dressing Self+Care (rooming Self+Care )ygiene Self+Care "oileting

Self+Care Assistance 'at#ing/)ygiene Self+Care Assistance Dressing/(rooming Self+Care Assistance Feeding Self+Care Assistance "oileting $nvironment 2anagement
NANDA Definition: %mpaired ability to perform or complete activities of daily living, suc# as feeding, dressing, bat#ing, toileting
FF
"#e nurse may encounter t#e patient ,it# a self+care deficit in t#e #ospital or in t#e community7 "#e deficit may be t#e result of transient limitations, suc# as t#ose one mig#t e!perience ,#ile recuperating from surgery< or t#e result of progressive deterioration t#at erodes t#e individualBs ability or ,illingness to perform t#e activities re/uired to care for #imself or #erself7 Careful e!amination of t#e patientBs deficit is re/uired in order to be certain t#at t#e patient is not failing at self+care because of a lack in material resources or a problem ,it# arranging t#e environment to suit t#e patientBs p#ysical limitations7 "#e nurse coordinates services to ma!imi1e t#e independence of t#e patient and to ensure t#at t#e environment t#at t#e patient lives in is safe and supportive of #is or #er special needs7 Defining C aracteristics: %nability to feed self independently, %nability to dress self independently, %nability to bat#e and groom self independently, %nability to perform toileting tasks independently, %nability to transfer from bed to ,#eelc#air, %nability to ambulate independently, %nability to perform miscellaneous common tasks suc# as telep#oning and ,riting Related !actors: .euromuscular impairment, secondary to cerebrovascular accident (C3A), 2usculoskeletal disorder suc# as r#eumatoid art#ritis, Cognitive impairment, $nergy deficit, *ain, Severe an!iety, Decreased motivation, $nvironmental barriers, impaired mobility or transfer ability7 "#$ected O%tco&es: *atient safely performs (to ma!imum ability) self+care activities7 Resources are identified ,#ic# are useful in optimi1ing t#e autonomy and independence of t#e patient7 Ongoing Assess&ent
Assess ability to carry out AD5s (e7g7, feed, dress, groom, bat#e, toilet, transfer, and ambulate) on regular basis7 Determine t#e aspects of self care t#at are problematic to t#e patient7 T e $atient &ay only re*%ire assistance )it so&e self:care &eas%res(
Assess specific cause of eac# deficit (e7g7, ,eakness, visual problems, cognitive impairment)7 Different etiological factors &ay re*%ire &ore s$ecific inter+entions to enable self:care(
9::
Assess patientBs need for assistive devices7 T is increases inde$endence in AD8s $erfor&ance( Assess for need of #ome #ealt# care after disc#arge7 S ortened os$ital stays &ean t at $atients are &ore debilitated on disc arge fro& t e os$ital' and t at $atients need &ore assistance after disc arge(
%dentify preferences for food, personal care items, and ot#er t#ings7 T ese s%$$ort $atient<s indi+id%al and $ersonal $references(
Assist patient in accepting necessary amount of dependence7 If disease' in,%ry' or illness res%lting in self:care deficit is recent' $atient &ay need to grie+e before acce$ting t at de$endence is $ossible(
Set s#ort+range goals ,it# patient7 Assisting t e $atient to set realistic goals )ill decrease fr%stration( $ncourage independence, but intervene ,#en patient cannot perform7 An a$$ro$riate le+el of assisti+e care can $re+ent in,%ry )it acti+ities )it o%t ca%sing fr%stration( -se consistent routines and allo, ade/uate time for patient to complete tasks7 T is el$s $atient organi7e and carry o%t self:care skills( *rovide positive reinforcement for all activities attempted< note partial ac#ievements7 T is $ro+ides t e $atient )it an e#ternal so%rce of $ositi+e reinforce&ent( !eeding:
$ncourage patient to feed self as soon as possible (using unaffected #and, if appropriate)7 Assist ,it# setup as needed7 It is $robable t at t e do&inant and )ill also be t e affected and if t ere is %$$er e#tre&ity in+ol+e&ent(
$nsure t#at patient ,ears dentures and eyeglasses if needed7 Deficits &ay be e#aggerated if ot er senses or strengt s are not f%nctioning o$ti&ally(
9:9
Assure t#at consistency of diet is appropriate for patientBs ability to c#e, and s,allo,, as assessed by speec# t#erapist7 6ec anical $roble&s &ay $ro ibit t e $atient fro& eating(
*rovide patient ,it# appropriate utensils (e7g7, drinking stra,, food guard, rocking knife, nonskid place mat) to aid in self+feeding7 T ese ite&s increase o$$ort%nities for s%ccess( *lace patient in optimal position for feeding, preferably sitting up in a c#air< support arms, elbo,s, and ,rists as needed7 Consider appropriate setting for feeding ,#ere patient #as supportive assistance yet is not embarrassed7 "&barrass&ent or fear of s$illing food on self &ay inder $atient<s atte&$ts to feed self(
%f patient #as visual problems, advise t#e patient of t#e placement of food on t#e plate7 !ollo)ing C5A' $atients &ay a+e %nilateral neglect' and &ay ignore alf t e $late( Dressing3groo&ing:
*rovide privacy during dressing7 4atients &ay take longer to dress and &ay be fearf%l of breac es in $ri+acy( *rovide fre/uent encouragement and assistance as needed ,it# dressing7 T ese red%ce energy e#$endit%re and fr%stration( *lan daily activities so patient is rested before activity7 *rovide appropriate assistive devices for dressing as assessed by nurse and occupational t#erapist7 T e %se of a b%tton ook or of loo$ and $ile clos%res on clot es &ay &ake it $ossible for a $atient to contin%e inde$endence in t is self:care acti+ity(
*lace t#e patient in ,#eelc#air or stationary c#air7 T is assists )it s%$$ort ) en dressing( Dressing can be fatig%ing( $ncourage use of clot#ing one si1e larger7 T is ens%res easier dressing and co&fort( Suggest front+opening brassiere and #alf slips7 T ese &ay be easier to &anage( Suggest elastic s#oelaces or loop and pile closures on s#oes7 T ese eli&inate tying( *rovide makeup and mirror< assist as needed7 !ine &otor acti+ities &ay take &ore coordinated actions and &ay be beyond t e abilities of t e $atient( @at ing3 ygiene:
9:;
2aintain privacy during bat#ing as appropriate7 T e need for $ri+acy is f%nda&ental for &ost $atients( $nsure t#at needed utensils are close by7 T is conser+es energy and o$ti&i7es safety( %nstruct patient to select bat# time ,#en #e or s#e is rested and un#urried7 /%rrying &ay res%lt in accidents and t e energy re*%ired for t ese acti+ities &ay be s%bstantial( *rovide patient ,it# appropriate assistive devices (e7g7, long+#andled bat# sponge< s#o,er c#air< safety mats for floor< grab bars for bat# or s#o,er)7 T ese aid in bed bat ing( $ncourage patient to comb o,n #air (a one+#anded task)7 Suggest #airstyles t#at are lo,+ maintenance7 T is enables t e $atient to &aintain a%tono&y for as long as $ossible( $ncourage patient to perform minimal oral+facial #ygiene as soon after rising as possible7 Assist ,it# brus#ing teet# and s#aving, as needed7 Assist patient ,it# care of fingernails and toenails as re/uired7 4atients &ay re*%ire $odiatric care to $re+ent in,%ry to feet d%ring nail tri&&ing or beca%se s$ecial i&$le&ents are re*%ired to c%t nails(
0ffer fre/uent encouragement7 4atients often a+e diffic%lty seeing $rogress(
Toileting:
$valuate or document previous and current patterns for toileting< institute a toileting sc#edule t#at factors t#ese #abits into t#e program7 T e effecti+eness of t e bo)el or bladder $rogra& )ill be en anced if t e nat%ral and $ersonal $atterns of t e $atient are res$ected(
*rovide privacy ,#ile patient is toileting7 8ack of $ri+acy &ay in ibit t e $atient<s ability to e+ac%ate bo)el and bladder( 6eep call lig#t ,it#in reac# and instruct patient to call as early as possible7 T is enables staff &e&bers to a+e ti&e to assist )it transfer to co&&ode or toilet( Assist patient in removing or replacing necessary clot#ing7 Clot ing t at is diffic%lt to get in and o%t of &ay co&$ro&ise a $atient<s ability to be continent( $ncourage use of commode or toilet as soon as possible7 4atients are &ore effecti+e in e+ac%ating bo)el and bladder ) en sitting on a co&&ode( So&e $atients find it i&$ossible to toilet on a bed$an( 9:>
0ffer bedpan or place patient on toilet every 9 to 9K #ours during day and t#ree times during nig#t7 T is eli&inates incontinence( Ti&e inter+als can be lengt ened as t e $atient begins to e#$ress t e need to toilet on de&and(
Closely monitor patient for loss of balance or fall7 6eep commode and toilet tissue near t#e bedside for nig#ttime use7 4atients &ay r%s readiness to a&b%late to t e toilet or co&&ode d%ring t e nig t beca%se of fear of soiling t e&sel+es and &ay fall in t e $rocess(
Transferring3a&b%lation:
*lan teac#ing session for transferring/,alking ,#en patient is rested7 Tasks re*%ire energy( !atig%ed $atients &ay a+e &ore diffic%lty and &ay beco&e %nnecessarily fr%strated(
Assist ,it# bed mobility by doing t#e follo,ing
$ncourage patient to use t#e stronger side (if appropriate) as best as possible7 Stroke $atients e#$erience )eakness in t eir do&inant side; t erefore it )ill be necessary for t e& to de+elo$ &%scle strengt and coordination on t e stronger side( Allo, patient to ,ork at o,n rate of speed7 6any factors &ay infl%ence a $atient<s ability to &o+e freely' and eac of t ese factors &%st be considered ) en de+elo$ing3teac ing a $atient a ne) syste& for self:care( It )ill take ti&e for t e $atient to learn and t en gain confidence in is or er ability to $erfor& t ese ne) self:care &eas%res( 4#en patient is sitting up at side of bed, instruct #im or #er not to pull on caregiver7 T is &ay ca%se caregi+er to lose balance and fall(
T is $re+ents disabling contract%res' $ress%re sores' and &%scle )eakness fro& dis%se(
9:?
4#en transferring to ,#eelc#air, al,ays place c#air on patientBs stronger side at slig#t angle to bed and lock brakes7 4atient )ill )eig t:bear on t e stronger side( 4#en minimal assistance is needed, stand on patientBs ,eak side and place nurseBs #and under patientBs ,eak arm7 -CAR"GI5"R: Gee$ yo%r feet )ell a$art; lift )it legs' not back' to $re+ent back strain(.
For moderate assistance, place caregiverBs arms under bot# armpits ,it# caregiverBs #ands on patientBs back7 T is forces $atient to kee$ is or er )eig t for)ard( For ma!imum assistance, place rig#t knee against patientBs strong knee, grasp patient around ,aist ,it# bot# arms, and pull #im or #er for,ard< encourage patient to put ,eig#t on strong side7 T is stance &a#i&i7es $atient s%$$ort ) ile $rotecting t e care $ro+ider fro& back in,%ry(
Assist ,it# ambulation< teac# t#e use of ambulation devices suc# as canes, ,alkers, and crutc#es

Stand on patientBs ,eak side7 T is en ances $atient safety( %f using cane, place cane in patientBs strong #and and ensure proper foot+cane se/uence7 T is assists )it balance and s%$$ort(
6iscellaneo%s skills:
"elep#one $valuate need for adaptive e/uipment t#roug# t#erapy department (e7g7, pus#button p#one, larger numbers, increased volume)7 4atients )ill re*%ire an effecti+e tool for co&&%nicating needs fro& o&e(
4riting Supply patient ,it# felt+tip pens7 T ese &ark )it little $ress%re and are easier to %se( $valuate need for splint on ,riting #and7 T is assists in olding t e )riting de+ice(
*rovide supervision for eac# activity until patient performs skill competently and is safe in independent care< reevaluate regularly to be certain t#at t#e patient is maintaining skill level and remains safe in environment7 T e $atient<s ability to $erfor& self:care &eas%res &ay c ange often o+er ti&e and )ill need to be assessed reg%larly(
$ncourage ma!imum independence7
9:=

*lan teac#ing sessions so patient #as time to practice tasks7 %nstruct patient in use of assistive devices as appropriate7 "eac# family and caregivers to foster independence and to intervene if t#e patient becomes fatigued, is unable to perform task, or becomes e!cessively frustrated7 T is de&onstrates caring and concern b%t does not interfere )it $atient<s efforts to ac ie+e inde$endence(
Risk for I&$aired Skin Integrity

4ress%re Sores; 4ress%re Ulcers; @ed Sores; Dec%bit%s Care NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

Risk Control Risk Detection "issue %ntegrity Skin and 2ucous 2embranes

*ressure -lcer *revention Skin Surveillance
NANDA Definition: At risk for skin being adversely altered %mmobility, ,#ic# leads to pressure, s#ear, and friction, is t#e factor most likely to put an individual at risk for altered skin integrity7 Advanced age< t#e normal loss of elasticity< inade/uate nutrition< environmental moisture, especially from incontinence< and vascular insufficiency potentiate t#e effects of pressure and #asten t#e development of skin breakdo,n7 (roups of persons ,it# t#e #ig#est risk for altered skin integrity are t#e spinal cord in&ured, t#ose ,#o are 9:C
confined to bed or ,#eelc#air for prolonged periods of time, t#ose ,it# edema, and t#ose ,#o #ave altered sensation t#at triggers t#e normal protective ,eig#t s#ifting7 *ressure relief and pressure reduction devices for t#e prevention of skin breakdo,n include a ,ide range of surfaces, specialty beds and mattresses, and ot#er devices7 *reventive measures are usually not reimbursable, even t#oug# costs related to treatment once breakdo,n occurs are greater7 Risk !actors: $!tremes of age, %mmobility, *oor nutrition, 2ec#anical forces (e7g7, pressure, s#ear, friction), *ronounced bony prominences, *oor circulation, Altered sensation, %ncontinence , $dema, $nvironmental moisture, )istory of radiation, )ypert#ermia or #ypot#ermia, Ac/uired immunodeficiency syndrome (A%DS), "#$ected O%tco&es: *atientBs skin remains intact, as evidenced by no redness over bony prominences and capillary refill less t#an C seconds over areas of redness7
Ongoing Assess&ent
Determine age7 "lderly $atients< skin is nor&ally less elastic and as less &oist%re' &aking for ig er risk of skin i&$air&ent( Assess general condition of skin7 /ealt y skin +aries fro& indi+id%al to indi+id%al' b%t s o%ld a+e good t%rgor -an indication of &oist%re.' feel )ar& and dry to t e to%c ' be free of i&$air&ent -scratc es' br%ises' e#coriation' ras es.' and a+e *%ick ca$illary refill -HL seconds.(
Specifically assess skin over bony prominences (e7g7, sacrum, troc#anters, scapulae, elbo,s, #eels, inner and outer malleolus, inner and outer knees, back of #ead)7 Areas ) ere skin is stretc ed ta%tly o+er bony $ro&inences are at ig er risk for breakdo)n beca%se t e $ossibility of isc e&ia to skin is ig as a res%lt of co&$ression of skin ca$illaries bet)een a ard s%rface -e(g(' &attress' c air' or table. and t e bone(
Assess patientBs a,areness of t#e sensation of pressure7 Nor&ally' indi+id%als s ift t eir )eig t off $ress%re areas e+ery fe) &in%tes; t is occ%rs &ore or less a%to&atically' e+en d%ring slee$( 4atients )it decreased sensation are %na)are of %n$leasant
9:D
sti&%li -$ress%re. and do not s ift )eig t( T is res%lts in $rolonged $ress%re on skin ca$illaries' and %lti&ately' skin isc e&ia(
Assess patientBs ability to move (e7g7, s#ift ,eig#t ,#ile sitting, turn over in bed, move from bed to c#air)7 I&&obility is t e greatest risk factor in skin breakdo)n( Assess patientBs nutritional status, including ,eig#t, ,eig#t loss, and serum albumin levels7 An alb%&in le+el less t an 0(> g3dl is a gra+e sign' indicating se+ere $rotein de$letion( Researc as s o)n t at $atients ) ose ser%& alb%&in is less t an 0(> g3dl are at ig risk for skin breakdo)n' all ot er factors being e*%al(
Assess for edema7 Skin stretc ed ta%tly o+er ede&ato%s tiss%e is at risk for i&$air&ent( Assess for #istory of radiation t#erapy7 Radiated skin beco&es t in and friable' &ay a+e less blood s%$$ly' and is at ig er risk for breakdo)n( Assess for #istory or presence of A%DS7 "arly &anifestations of /I5:related diseases &ay incl%de skin lesions -e(g(' Ga$osi<s sarco&a.; additionally' beca%se of t eir i&&%noco&$ro&ise' $atients )it AIDS often a+e skin breakdo)n(
Assess for fecal and/or urinary incontinence7 T e %rea in %rine t%rns into a&&onia )it in &in%tes and is ca%stic to t e skin( Stool &ay contain en7y&es t at ca%se skin breakdo)n( Use of dia$ers and incontinence $ads )it $lastic liners tra$s &oist%re and astens breakdo)n(
Assess for environmental moisture (e7g7, ,ound drainage, #ig# #umidity)7 6oist%re &ay contrib%te to skin &aceration( Assess surface t#at patient spends ma&ority of time on (e7g7, mattress for bedridden patient, cus#ion for persons in ,#eelc#airs)7 4atients ) o s$end t e &a,ority of ti&e on one s%rface need a $ress%re red%ction or $ress%re relief de+ice to distrib%te $ress%re &ore e+enly and lessen t e risk for breakdo)n(
Assess amount of s#ear (pressure e!erted laterally) and friction (rubbing) on patientBs skin7 A co&&on ca%se of s ear is ele+ating t e ead of t e $atient<s bed: t e body<s )eig t is s ifted do)n)ard onto t e $atient<s sacr%&( Co&&on ca%ses of friction incl%de t e $atient r%bbing eels or elbo)s against bed linen' and &o+ing t e $atient %$ in bed )it o%t t e %se of a lift s eet(
9:E
Reassess skin often and ,#enever t#e patientBs condition or treatment plan results in an increased number of risk factors7 T e incidence and onset of skin breakdo)n is directly related to t e n%&ber of risk factors $resent(
%f patient is restricted to bed
$ncourage implementation and posting of a turning sc#edule, restricting time in one position to ; #ours or less and customi1ing t#e sc#edule to patientBs routine and caregiverBs needs7 A sc ed%le t at does not interfere )it t e $atient<s and caregi+ers< acti+ities is &ost likely to be follo)ed(
$ncourage implementation of pressure+relieving devices commensurate ,it# degree of risk for skin impairment
For lo,+risk patients good+/uality (dense, at least = inc#es t#ick) foam mattress overlay "gg crate &attresses less t an A to > inc es t ick do not relie+e $ress%re; beca%se t ey are &ade of foa&' &oist%re can be tra$$ed( A false sense of sec%rity )it t e %se of t ese &attresses can delay initiation of de+ices %sef%l in relie+ing $ress%re(
For moderate risk patients ,ater mattress, static or dynamic air mattress In t e o&e' a )aterbed is a good alternati+e( For #ig#+risk patients or t#ose ,it# e!isting stage %%% or %3 pressure sores (or ,it# stage %% pressure sores and multiple risk factors) lo,+air+loss beds (2ediscus, Fle!icare, 6inair) or air+fluidi1ed t#erapy (Clinitron, Skytron) 8o):air:loss beds are constr%cted to allo) ele+ated ead of bed -/O@. and $atient transfer( T ese s o%ld be %sed ) en $%l&onary concerns necessitate ele+ating /O@ or ) en getting $atient %$ is feasible( EAir:fl%idi7edE t era$y s%$$orts $atient<s )eig t at )ell belo) ca$illary closing $ress%re b%t restricts getting $atient o%t of bed easily(
$ncourage patient and/or caregiver to maintain functional body alignment7 5imit c#air sitting to ; #ours at any one time7 4ress%re o+er sacr%& &ay e#ceed ;11 && /g $ress%re d%ring sitting( T e $ress%re necessary to close skin ca$illaries is aro%nd 20 && /g; any $ress%re greater t an 20 && /g res%lts in skin isc e&ia(
9:F
$ncourage ambulation if patient is able7 %ncrease tissue perfusion by massaging around affected area7 6assaging reddened area &ay da&age skin f%rt er( Clean, dry, and moisturi1e skin, especially over bony prominences, t,ice daily or as indicated by incontinence or s,eating7 %f po,der is desirable, use medical+grade cornstarc#< avoid talc7
$ncourage ade/uate nutrition and #ydration

;::: to >::: kcal/day (more if increased metabolic demands)7 Fluid intake of ;::: ml/day unless medically restricted7 /ydrated skin is less $rone to breakdo)n( 4atients )it li&ited cardio+asc%lar reser+e &ay not be able to tolerate t is &%c fl%id(
$ncourage use of lift s#eets to move patient in bed and discourage patient or caregiver from elevating )0' repeatedly7 T ese &eas%res red%ce s earing forces on t e skin( 5eave blisters intact by ,rapping in gau1e, or applying a #ydrocolloid (Duoderm, S,een+ Appeal) or a vapor+permeable membrane dressing (0p+Site, "egaderm)7 @listers are sterile nat%ral dressings( 8ea+ing t e& intact &aintains t e skin<s nat%ral f%nction as barrier to $at ogens ) ile t e i&$aired area belo) t e blister eals(

Consult dietitian as appropriate7 "eac# patient and caregiver t#e cause(s) of pressure ulcer development

*ressure on skin, especially over bony prominences %ncontinence *oor nutrition S#earing or friction against skin
Reinforce t#e importance of mobility, turning, or ambulation in prevention of pressure ulcers7 "eac# patient or caregiver t#e proper use and maintenance of pressure+relieving devices to be used at #ome7
99:
Dist%rbed Slee$ 4attern

Inso&nia NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

An!iety Control Sleep
Sleep $n#ancement
NANDA Definition: "ime+limited disruption of sleep (natural, periodic suspension of consciousness) amount and /uality
999
Sleep is re/uired to provide energy for p#ysical and mental activities7 "#e sleep+,ake cycle is comple!, consisting of different stages of consciousness rapid eye movement (R$2) sleep, nonrapid eye movement (.R$2) sleep, and ,akefulness7 As persons age t#e amount of time spent in R$2 sleep diminis#es7 "#e amount of sleep t#at individuals re/uire varies ,it# age and personal c#aracteristics7 %n general t#e demands for sleep decrease ,it# age7 $lderly patients sleep less during t#e nig#t, but may take more naps during t#e day to feel rested7 Disruption in t#e individualBs usual diurnal pattern of sleep and ,akefulness may be temporary or c#ronic7 Suc# disruptions may result in bot# sub&ective distress and apparent impairment in functional abilities7 Sleep patterns can be affected by environment, especially in #ospital critical care units7 "#ese patients e!perience sleep disturbance secondary to t#e noisy, brig#t environment, and fre/uent monitoring and treatments7 Suc# sleep disturbance is a significant stressor in t#e intensive care unit (%C-) and can affect recovery7 0t#er factors t#at can affect sleep patterns include temporary c#anges in routines suc# as in traveling, &et lag, s#aring a room ,it# anot#er, use of medications (especially #ypnotic and antian!iety drugs), alco#ol ingestion, nig#t+s#ift rotations t#at c#ange oneBs circadian r#yt#ms, acute illness, or emotional problems suc# as depression or an!iety7 "#is care plan focuses on general disturbances in sleep patterns and does not address organic problems suc# as narcolepsy or sleep apnea7 Defining C aracteristics: 3erbal complaints of difficulty falling asleep, A,akening earlier or later t#an desired, %nterrupted sleep, 3erbal complaints of not feeling rested, Restlessness, %rritability, Do1ing, La,ning, Altered mental status, Difficulty in arousal, C#ange in activity level, Altered facial e!pression (e7g7, blank look, fatigued appearance) Related !actors: *ain/discomfort, $nvironmental c#anges, An!iety/fear, Depression, 2edications, $!cessive or inade/uate stimulation, Abnormal p#ysiological status or symptoms (e7g7, dyspnea, #ypo!ia, or neurological dysfunction), .ormal c#anges associated ,it# aging7 "#$ected O%tco&es: *atient ac#ieves optimal amounts of sleep as evidenced by rested appearance, verbali1ation of feeling rested, and improvement in sleep pattern7
99;
Ongoing Assess&ent
Assess past patterns of sleep in normal environment amount, bedtime rituals, dept#, lengt#, positions, aids, and interfering agents7 Slee$ $atterns are %ni*%e to eac indi+id%al(
Assess patientBs perception of cause of sleep difficulty and possible relief measures to facilitate treatment7 !or s ort:ter& $roble&s' $atients &ay a+e insig t into t e etiological factors of t e $roble& -e(g(' fear o+er res%lts of a diagnostic test' concern o+er a da%g ter getting di+orced' de$ression o+er t e loss of a lo+ed one.( Gno)ing t e s$ecific etiological factor )ill g%ide a$$ro$riate t era$y(
Document nursing or caregiver observations of sleeping and ,akeful be#aviors7 Record number of sleep #ours7 .ote p#ysical (e7g7, noise, pain or discomfort, urinary fre/uency) and/or psyc#ological (e7g7, fear, an!iety) circumstances t#at interrupt sleep7 Often' t e $atient<s $erce$tion of t e $roble& &ay differ fro& ob,ecti+e e+al%ation(
%dentify factors t#at may facilitate or interfere ,it# normal patterns7 Considerable conf%sion and &yt s abo%t slee$ e#ist( Gno)ledge of its role in ealt 3)ellness and t e )ide +ariation a&ong indi+id%als &ay allay an#iety' t ereby $ro&oting rest and slee$(
$valuate timing or effects of medications t#at can disrupt sleep7 In bot t e os$ital and o&e care settings' $atients &ay be follo)ing &edication sc ed%les t at re*%ire a)akening in t e early &orning o%rs( Attention to c anges in t e sc ed%le or c anges to once:a:day &edication &ay sol+e t e $roble&(
%nstruct patient to follo, as consistent a daily sc#edule for retiring and arising as possible7 T is $ro&otes reg%lation of t e circadian r yt &' and red%ces t e energy re*%ired for ada$tation to c anges(
%nstruct to avoid #eavy meals, alco#ol, caffeine, or smoking before retiring7 T o%g %nger can also kee$ one a)ake' gastric digestion and sti&%lation fro& caffeine and nicotine can dist%rb slee$(
99>
%nstruct to avoid large fluid intake before bedtime7 T is el$s $atients ) o ot er)ise &ay need to +oid d%ring t e nig t( %ncrease daytime p#ysical activities as indicated7 T is red%ces stress and $ro&otes slee$(
%nstruct to avoid strenuous activity before bedtime7 O+erfatig%e &ay ca%se inso&nia(
Discourage pattern of daytime naps unless deemed necessary to meet sleep re/uirements or if part of oneBs usual pattern7 Na$$ing can disr%$t nor&al slee$ $atterns; o)e+er' elderly $atients do better )it fre*%ent na$s d%ring t e day to co%nter t eir s orter nig tti&e slee$ sc ed%les(
Suggest use of soporifics suc# as milk7 6ilk contains 8:try$to$ an' ) ic facilitates slee$( Recommend an environment conducive to sleep or rest (e7g7, /uiet, comfortable temperature, ventilation, darkness, closed door)7 Suggest use of earplugs or eye s#ades as appropriate7
Suggest engaging in a rela!ing activity before retiring (e7g7, ,arm bat#, calm music, reading an en&oyable book, rela!ation e!ercises)7 $!plain t#e need to avoid concentrating on t#e ne!t dayBs activities or on oneBs problems at bedtime7 Ob+io%sly' t is )ill interfere )it ind%cing a restf%l state( 4lanning a designated ti&e d%ring t e ne#t day to address t ese concerns &ay $ro+ide $er&ission to Elet goE of t e )orries at bedti&e(
Suggest using #ypnotics or sedatives as ordered< evaluate effectiveness7 @eca%se of t eir $otential for c%&%lati+e effects and generally li&ited $eriod of benefit' %se of y$notic &edications s o%ld be t o%g tf%lly considered and a+oided if less aggressi+e &eans are effecti+e( Different dr%gs are $rescribed de$ending on ) et er t e $atient as tro%ble falling aslee$ or staying aslee$( 6edications t at s%$$ress R"6 slee$ s o%ld be a+oided(
%f unable to fall asleep after about >: to ?= minutes, suggest getting out of bed and engaging in a rela!ing activity7 T e bed s o%ld not be associated )it )akef%lness( !or $atients ) o are os$itali7ed:
99?
*rovide nursing aids (e7g7, back rub, bedtime care, pain relief, comfortable position, rela!ation tec#ni/ues)7 T ese aids $ro&ote rest( 0rgani1e nursing care

$liminate nonessential nursing activities7 *repare patient for necessary anticipated interruptions/disruptions7
T is $ro&otes &ini&al interr%$tion in slee$ or rest(
Attempt to allo, for sleep cycles of at least F: minutes7 "#$eri&ental st%dies a+e indicated t at L1 to F1 &in%tes are needed to co&$lete one slee$ cycle' and t e co&$letion of an entire cycle is necessary to benefit fro& slee$(
2ove patient to room fart#er from t#e nursing station if noise is a contributing factor7 *ost a GDo not disturbG sign on t#e door7

"eac# about possible causes of sleeping difficulties and optimal ,ays to treat t#em7 %nstruct on nonp#armacological sleep en#ancement tec#ni/ues7
Ineffecti+e T era$e%tic Regi&en 6anage&ent


Self+2odification Assistance "eac#ing %ndividual
NANDA Definition: *attern of regulating and integrating into daily living a program for treatment of illness and t#e se/uelae of illness t#at is unsatisfactory for meeting specific #ealt# goals 4it# t#e ongoing c#anges in #ealt# care, patients are being e!pected to be comanagers of t#eir care7 "#ey are being disc#arged from #ospitals earlier, and are faced ,it# increasing comple! 99=
t#erapeutic regimens to be #andled in t#e #ome environment7 5ike,ise, patients ,it# c#ronic illness often #ave limited access to #ealt# care providers and are e!pected to assume responsibility for managing t#e nuances of t#eir disease (e7g7, #eart failure patients taking an e!tra furosemide @5asi!A tablet for a ;+pound ,eig#t gain)7 *atients ,it# sensory+perception deficits, altered cognition, financial limitations, and t#ose lacking support systems may find t#emselves over,#elmed and unable to follo, t#e treatment plan7 $lderly patients, ,#o often e!perience most of t#e above problems, are especially at #ig# risk for ineffective management of t#e t#erapeutic plan7 0t#er vulnerable populations include patients living in adverse social conditions (e7g7, poverty, unemployment, little education)< patients ,it# emotional problems (e7g7, depression over t#e illness being treated or ot#er life crises or problems)< and patients ,it# substance abuse problems7 Culture, et#nicity, and religion may influence oneBs #ealt# beliefs, #ealt# practices (e7g7, folk medicine, alternative t#erapies), access to #ealt# services, and assertiveness in pursuing specific #ealt# care services7 Defining C aracteristics: C#oices of daily living ineffective for meeting t#e goals of treatment or prescription program, %ncreased illness, 3erbali1ed desire to manage illness, 3erbali1ed difficulty ,it# prescribed regimen, 3erbali1ation by patient t#at #e or s#e did not follo, prescribed regimen7 Related !actors: Comple!ity of #ealt# care, Comple!ity of t#erapeutic regimen, Decisional conflicts, $conomic difficulties, $!cessive demands made on individual or family, Family conflict, Family patterns of #ealt# care, %nade/uate number and types of cues to action, 6no,ledge deficit of prescribed regimen, *erceived seriousness, *erceived susceptibility, *erceived barriers, Social support deficits, *erceived po,erlessness7 "#$ected O%tco&es: *atient describes intention to follo, prescribed regimen7 *atient describes or demonstrates re/uired competencies7 *atient identifies appropriate resources7 Ongoing Assess&ent
Assess prior efforts to follo, regimen7
99C
Assess for related factors t#at may negatively affect success ,it# follo,ing regimen7 Gno)ledge of ca%sati+e factors $ro+ides direction for s%bse*%ent inter+ention( T is &ay range fro& financial constraints to $ ysical li&itations(
Assess patientBs individual perceptions of #is or #er #ealt# problems7 According to t e /ealt @elief 6odel' $atient<s $ercei+ed s%sce$tibility to and $ercei+ed serio%sness and t reat of disease affect is or er co&$liance )it t e $rogra&( In addition' factors s%c as c%lt%ral $ eno&ena and eritage can affect o) $eo$le +ie) t eir ealt (
Assess patientBs confidence in #is or #er ability to perform desired be#avior7 According to t e self:efficacy t eory' $ositi+e con+iction t at one can s%ccessf%lly e#ec%te a be a+ior is correlated )it $erfor&ance and s%ccessf%l o%tco&e(
Assess patientBs ability to learn or remember t#e desired #ealt#+related activity7 Cogniti+e i&$air&ents need to be identified so an a$$ro$riate alternati+e $lan can be de+ised( !or e#a&$le' t e 6ini:6ental Stat%s "#a&ination can be %sed to identify &e&ory $roble&s t at co%ld interfere )it acc%rate $ill taking( Once identified' alternati+e actions s%c as %sing egg cartons to dis$ense &edications' or daily $ one re&inders' can be instit%ted(
Assess patientBs ability to perform t#e desired activity7 4atients )it li&ited financial reso%rces &ay be %nable to $%rc ase s$ecial diet foods s%c as t ose lo) in fat or lo) in salt( 4atients )it art ritis &ay be %nable to o$en c ild:$roof $ill containers(
%nclude patient in planning t#e treatment regimen7 4atients ) o beco&e co&anagers of t eir care a+e a greater stake in ac ie+ing a $ositi+e o%tco&e( T ey kno) best t eir $ersonal and en+iron&ental barriers to s%ccess(
"ailor t#e t#erapy to patientBs lifestyle (e7g7, taking diuretics at dinner if ,orking during t#e day)7 %nform patient of t#e benefits of ad#erence to prescribed regimen7 Increased kno)ledge fosters co&$liance( Simplify t#e regimen7 Suggest long+acting forms of medications and eliminate unnecessary medication7 T e greater t e n%&ber of ti&es d%ring t e day t at $atients need to take 99D
&edications' t e greater t e risk of not follo)ing t ro%g ( 4oly$ ar&acy is a significant $roble& )it elderly $atients( Atte&$t to red%ce nonessential dr%g %sage(
$liminate unnecessary clinic visits7 T e $ ysical de&ands of tra+eling to an a$$oint&ent' t e financial costs inc%rred -loss of day<s )ork' c ild care.' t e negati+e feelings of being Etalked do)n toE by ealt care $ro+iders not fl%ent in $atient<s lang%age' as )ell as t e co&&only long )aits can ca%se $atients to a+oid follo):%$s ) en t ey are re*%ired( Tele$ one follo):%$ &ay be s%bstit%ted as a$$ro$riate(
Develop a system for patient to monitor #is or #er o,n progress7 Develop ,it# patient a system of re,ards t#at follo, successful follo,+t#roug#7 Re)ards &ay consist of +erbal $raise' &onetary re)ards' s$ecial $ri+ileges -e(g(' earlier office a$$oint&ent' free $arking.' or tele$ one calls(
Concentrate on t#e be#aviors t#at ,ill make t#e greatest contribution to t#e t#erapeutic effect7 %f negative side effects of prescribed treatment are a problem, e!plain t#at many side effects can be controlled or eliminated7 Nonad erence beca%se of &edication side effects is a co&&only re$orted $roble&( /ealt care $ro+iders need to deter&ine act%al etiological factors for side effects' and $ossible inter$lay )it o+er:t e:co%nter &edications( 4atients like)ise re$ort fatig%e or &%scle cra&$s )it e#ercise( T e e#ercise $rescri$tion &ay need to be re+ised(
%f patient lacks ade/uate support in follo,ing prescribed treatment plan, initiate referral to a support group (e7g7, American Association of Retired *ersons @AAR*A, American Diabetes Association, senior groups, ,eig#t loss programs, L 2e, smoking cessation clinics, stress management classes, social services)7 Gro%$s t at co&e toget er for &%t%al s%$$ort and infor&ation can be beneficial(
-se a variety of teac#ing met#ods7 Different $eo$le learn in different )ays( 6atc t e learning style )it t e ed%cational a$$roac ( !or so&e $atients t is &ay re*%ire grocery s o$$ing for E ealt y foodsE )it a dietitian' or a o&e +isit by t e n%rse to re+ie) a $syc o&otor skill(
99E
%ntroduce complicated t#erapy one step at a time7 T is allo)s learner to concentrate &ore co&$letely on one to$ic at a ti&e( %nstruct patient on t#e importance of reordering medications ; to > days before running out7 Alt o%g &any c%lt%res in t e United States are f%t%re:oriented and are concerned )it &eas%res to $re+ent illness' ot er c%lt%res are &ore oriented to t e $resent( T is difference in ti&e orientation &ay need to be addressed(
%nclude significant ot#ers in e!planations and teac#ing7 "nco%rage t eir s%$$ort and assistance in follo)ing $lans( T is &ay en ance o+erall ada$tation to t e $rogra&( Allo, learner to practice ne, skills< provide immediate feedback on performance7 T is allo)s $atient to %se ne) infor&ation i&&ediately' t %s en ancing retention( I&&ediate feedback allo)s learner to &ake corrections rat er t an $ractice t e skill incorrectly(
Role+play scenarios ,#en nonad#erence to plan may easily occur7 Demonstrate appropriate be#aviors7 Rela$se $re+ention needs to be addressed early in t e treat&ent $lan( /el$ing $atient e#$and is or er re$ertoire of res$onses to diffic%lt sit%ations assists in &eeting treat&ent goals(
Dist%rbed Sensory 4erce$tion: A%ditory

/earing 8oss; /earing I&$aired; Deafness NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

)earing Compensation 'e#avior Risk Control )earing %mpairment
99F
Communication $n#ancement )earing Deficit $ar Care
NANDA Definition: C#ange in t#e amount or patterning of incoming stimuli accompanied by a diminis#ed, e!aggerated, distorted, or impaired response to suc# stimuli )earing loss is common among older adults but may also occur as t#e result of congenital e!posure to virus< during c#ild#ood after fre/uent ear infections or trauma< and during adult#ood as t#e result of trauma, infection, or e!posure to occupational and/or environmental noise7 4#en #earing loss is profound and precedes language development, t#e ability to learn speec# and interact ,it# #earing peers can be severely impaired7 4#en #earing is impaired or lost later in life, serious emotional and social conse/uences can occur, including depression and isolation7 Some causes of #earing loss are surgically correctable7 2any #earing assistive devices and services are available to #elp t#e #earing+impaired individual7 .ursing interventions ,it# t#e #earing impaired are aimed at assisting t#e individual in effective communication despite t#e loss of normal #earing7 Defining C aracteristics: Asking ot#ers to repeat spoken messages, %nappropriate response to /uestions, )ead tilting, Cupping #ands around ears, Social avoidance or ,it#dra,al, %rritability, Difficulty learning or follo,ing directions, Di11iness, $ar pain Related !actors: 2iddle ear in&uries secondary to penetration of eardrum, )istory of #ead trauma, especially direct blo, to ear(s), *rolonged or cumulative e!posure to environmental noise greater t#an E= d', 0tosclerosis, 2eniereBs disease, *resbycusis (loss of #earing associated ,it# aging), Acoustic neuroma, Congenital rubella e!posure, 0toto!ic drug use, C#ronic or recurring otitis media, %noperative or poorly fitted #earing aids, Accumulated ear,a! "#$ected O%tco&es: *atient ac#ieves optimal functioning ,it#in limits of #earing impairment as evidenced by ability to communicate effectively and to engage in meaningful activities7 Ongoing Assess&ent
Assess patientBs ability to #ear by performing t#e follo,ing
9;:
As screening, note patientBs ability to #ear and appropriately respond to normal conversational voice< do t#is ,it#in patientBs sig#t, t#en again from out of patientBs sig#t7 4atients &ay rely on li$:reading to a greater e#tent t an t ey are a)are( Ask family or caregivers about t#eir perception of patientBs #earing impairment7 Revie, audiogram, if available7 T is diagnostic st%dy indicates bot ty$e and a&o%nt of earing loss(
Assess age7 Ne%rosensory earing loss affects &any older indi+id%als; ig :$itc ed so%nds' and t e ability to co&$re end so&e consonants' are t e earliest effects( 4atients &ay be %na)are of $rogressi+e earing loss; fa&ily' friends' and caregi+ers often first notice re*%ests for +erbal re$etition' lack of res$onse to +erbali7ations' and &isans)ered *%estions(
Assess ,#et#er #earing loss is recent, progressive, or present since c#ild#ood7 Ad%lts )it ne) or $rogressi+e earing loss re*%ire attention to t e e&otional and social i&$lications of i&$aired co&&%nication' ) ereas t ose ) o a+e ad earing loss since birt or c ild ood $robably a+e t e skills' tools' and reso%rces a+ailable to co$e )it earing i&$air&ent( earing loss(
Revie, medical #istory7 /istory of ead or ear tra%&a and fre*%ent bo%ts )it ear infections are often associated )it Revie, e!posure to environmental noise, eit#er as t#e result of occupation, recreation, or accident7 Occ%$ational Safety and /ealt Act -OS/A. re*%ires earing $rotection in )ork$laces )it noise le+els e#ceeding F1 d@( Co%ng $ersons ) o fre*%ent rock concerts or listen to +ery lo%d &%sic $lace t e&sel+es at risk for earing loss( /earing loss t at res%lts fro& noise is not re+ersible(
Revie, recent use of drugs t#at are ototo!ic7 As$irin' *%inidine' so&e c e&ot era$e%tic agents' and t e a&inoglycosides are kno)n ototo#ic agents( Wit dra)al of t ese dr%gs ) en earing i&$air&ent occ%rs often allo)s for f%ll ret%rn of earing(
C#eck ears for ear,a!7 Wa# $re+ents so%nd trans&ission and &ay clog earing aid-s.( .ote/investigate social and emotional impact of #earing loss7 8oss of earing &ay lead to recl%si+eness' isolation' de$ression' and )it dra)al fro& %s%al acti+ities( T e decision to )ear a earing aid is often resisted beca%se of t e social stig&a $ercei+ed in con,%nction )it aging and loss of abilities(
9;9
For patients ,it# #earing aids

.ote condition/age of #earing aid(s)7 .ote fre/uency ,it# ,#ic# patient ,ears #earing aid(s)7 C#eck #earing aid(s) for fres#, functional batteries7 C#eck #earing aid(s) for ,a! impaction7
Assess for drainage from ear canal7 4%r%lent' fo%l:s&elling drainage indicates an infection; sero%s' &%coid' or bloody drainage &ay indicate eff%sion of t e &iddle ear after an %$$er res$iratory or sin%s infection(
Culture any drainage from t#e ear canal(s)7 T is deter&ines $resence of infectio%s $at ogens( Ask patient ,#et#er t#e ear(s) is painful7 4ain is a sy&$to& of increased $ress%re be ind t e eardr%&' %s%ally a res%lt of infection( Assess for di11iness, dyse/uilibrium7 Disorders of t e ear -e(g(' 6eniere<s disease. &ay be acco&$anied by di77iness beca%se of t e inner ear<s role in &aintenance of e*%ilibri%&(
Assess patientBs ability to effectively administer ear drops7

-se touc# and eye contact7 T ese gain $atient<s attention( 4#en speaking, do t#e follo,ing
Reduce or minimi1e environmental noise7 Red%ce noise so t at s$eaker does not a+e to co&$ete to be eard( Face patient in good lig#t and keep #ands a,ay from mout#7 T is en ances $atient<s %se of li$:reading' facial e#$ressions' and gest%ring( Speak close to patientBs GbetterG ear, as appropriate7 Avoid s#outing or yelling7 T is $re+ents %&iliation( -se simple language and s#ort sentences7 Speak slo,ly7
-se grease boards, computers, or ot#er ,riting tools7 T ese el$ co&&%nicate )it $rofo%ndly earing:i&$aired indi+id%als(
9;;
For patients ,it# #earing aid(s), ensure t#at #earing aid(s) is in place, clean and ,orking7 4atients )it ne) earing aid-s. need ti&e to ad,%st to t e so%nd $rod%ced( "nco%rage&ent is often needed' es$ecially a&ong elderly $atients ) o &ay decide t at t e earing aid-s. is not )ort t e effort(
*rovide encouragement to use #earing aid(s)7 *repare patient for ear surgery7 Ty&$ano$lasty -re&o+al of dead tiss%e' restoration of bones )it $rost eses. and &astoidecto&y -re&o+al of all or $ortions of t e &iddle ear str%ct%res. are co&&on s%rgical treat&ents for earing loss(
"eac# patient or caregiver to administer ear medications7 Dro$s s o%ld be ad&inistered at roo& te&$erat%re to a+oid $ain and di77iness; ti$ of a$$licator or dro$$er s o%ld not be allo)ed to co&e into contact )it anyt ing( /ead s o%ld be $ositioned to allo) &edication to flo) into ear canal; t is $osition s o%ld be &aintained for ; to 0 &in%tes(
%nstruct patient or caregiver in safe tec#ni/ues for cleaning ears7 T in )as clot s and fingers are best for cleaning ears( Cotton:ti$$ed a$$licators s o%ld be a+oided to $re+ent inad+ertent in,%ry to eardr%&(
"eac# patient or caregiver use and care of #earing aid(s) and/or ot#er assistive #earing devices7 $!plore tec#nology suc# as amplifiers, modifiers for telep#ones, and services for t#e #earing impaired (e7g7, closed+caption "3, telep#one #earing+impaired assistance)7 T ese &ay assist t e earing:i&$aired $erson f%nction and $artici$ate in &eaningf%l acti+ities(
%nstruct patient in t#e importance of routine e!amination by an audiologist7 "#a&s detect c anges in earing or need for c ange in earing aid-s.(
9;>
Dist%rbed Sensory 4erce$tion: 5is%al

5ision 8oss; 6ac%lar Degeneration; @lindness NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

3isual Compensation 'e#avior Risk Control 3isual %mpairment

Communication $n#ancement 3isual Deficit $nvironmental 2anagement Self+$steem $n#ancement
NANDA Definition: C#ange in t#e amount or patterning of incoming stimuli, accompanied by a diminis#ed, e!aggerated, distorted, or impaired response to suc# stimuli 3isual impairment and/or loss of vision affects more t#an 9:: million Americans7 (enetics, aging, and c#ronic diseases suc# as diabetes and glaucoma account for t#e ma&ority of visual impairment7 "rauma, usually associated ,it# alco#ol use, also accounts for visual impairment or loss to a lesser degree7 Some forms of visual impairment can be corrected, eit#er by refraction (glasses, contact lenses), medications (used mainly in t#e treatment of glaucoma), or surgery (lens implants, keratorefractive procedures)7 "#ese include myopia (nearsig#tedness), #yperopia (farsig#tedness), astigmatism (caused by abnormal corneal curvature), and presbyopia (loss of accommodation as t#e result of normal, age+related c#anges in t#e lens)7 0t#er types of visual impairment or loss 9;?
cannot be corrected7 As t#e American population ages, visual impairment, including noncorrectable loss from progressive macular degeneration, is a gro,ing concern7 .ursing interventions in persons ,it# visual impairment are aimed at assisting t#e individual to cope ,it# t#e loss and remain functional and safe7 Ability to be independent ,it# self+care, especially in t#e management of medications, may re/uire ongoing supervision and/or institutionali1ation7 "#is care plan addresses needs of persons ,#o are out of t#eir usual environments (e7g7, in outpatient settings, #ospitals, or long+term care facilities)7 Defining C aracteristics:

Reported or measured c#anges in visual acuity C#ange in usual response to visual stimuli 5ack of eye+to+eye contact Abnormal eye movement Failure to locate distant ob&ects S/uinting, fre/uent blinking 'umping into t#ings Clumsy be#avior Closing of one eye to see Fre/uent rubbing of eye Deviation of eye

(ray opacities in eyes )ead tilting Disorientation An!iety Anger 3isual distortions %ncoordination )istory of falls, accidents
Related !actors Diabetes, (laucoma, Cataracts, Refractive disorders (myopia, #yperopia, astigmatism, presbyopia), 2acular degeneration, 0cular trauma, 0cular infection, Retinal detac#ment, Con&unctival 6aposiBs sarcoma of ac/uired immunodeficiency syndrome (A%DS)
Disease or trauma to visual pat#,ays or cranial nerves %%, %%%, %3, and 3%, secondary to Advanced age
stroke, intracranial aneurysms, brain tumor, trauma, myast#enia gravis, or multiple sclerosis
9;=
"#$ected O%tco&es: *atient ac#ieves optimal functioning ,it#in limits of visual impairment as evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities7 Ongoing Assess&ent
Assess age7 T e incidence of &ac%lar degeneration' cataracts' retinal detac &ents' diabetic retino$at y' and gla%co&a increase )it aging( Determine nature of visual symptoms, onset, and degree of visual loss7 Recent loss' loss o+er a long $eriod' or long:standing loss a+e different i&$lications for n%rsing inter+ention and t e $atient<s le+el of ada$tation or reso%rce %se( Since +is%al loss &ay occ%r grad%ally' *%antification of loss &ay be diffic%lt for t e $atient to artic%late(
Revie, medical #istory7 %n/uire about patient or family #istory of systemic or central nervous system (C.S) disease7 !a&ily or $atient istory of at erosclerosis' diabetes' t yroid disease' or y$ertension s o%ld be in+estigated as $ossible ca%se for +is%al loss(
Ask patient about specifics suc# as ability to read, see television, #istory of falls, or ability to self+medicate7 %n/uire about #istory of visual complaints, eye trauma, or ocular pain7 Assess central vision ,it# eac# eye, individually and toget#er7 5ision loss &ay be %nilateral' bilateral' central' and3or $eri$ eral' and &ay not affect bot eyes to t e sa&e e#tent(
Assess perip#eral field of vision and visual acuity7 Gla%co&a affects $eri$ eral +ision; its onset is insidio%s' and as no associated sy&$to&s( 6ac%lar degeneration affects central +ision' is &ore co&&on a&ong cigarette s&okers' and is irre+ersible(
Assess eye and lid for inflammation, edema, positional defects, and deviation7 T ese are correctable $roble&s t at can negati+ely affect +ision( Assess factors or aids t#at improve vision, suc# as glasses, contact lenses, or brig#t and/or natural lig#t7
9;C
$valuate patientBs ability to function ,it#in limits of visual impairment7 4ersonal a$$earance and condition of clot ing and s%rro%ndings are good indicators of t e $atient<s ada$tation to +is%al loss(
$valuate psyc#ological response to visual loss7 Anger' de$ression' and )it dra)al are co&&on res$onses( Self:estee& is often negati+ely affected(
%ntroduce self to patient, and ackno,ledge visual impairment7 T is red%ces $atient<s an#iety( 0rient patient to environment7 Orientation red%ces fear related to %nfa&iliar en+iron&ent( Do not make unnecessary c#anges in environment7 T is ens%res safety and &aintains ) at t e $atient as arranged(
*rovide ade/uate lig#ting7 T e %se of nat%ral or alogen lig ting is $referred to i&$ro+e +ision for $atients )it di&inis ed +ision( *lace meal tray, tissues, ,ater, and call lig#t ,it#in patientBs range of vision or reac#7 T ese ens%re safety and sense of inde$endence( Communicate type and degree of impairment to all involved in patientBs care7 T is en ances contin%ity of care( Recommend use of visual aids ,#en appropriate7 5is%al aids s%c as &agnifying glass' large:ty$e $rinted books' and &aga7ines enco%rage reading( *lace food on tray and plate in same place eac# meal and e!plain arrangement of food on tray and plate, using clock,ise se/uence7 $ncourage use of sense of touc#7 To%c enco%rages $atient to beco&e fa&iliar )it %nfa&iliar ob,ects( $!plain sounds or ot#er unusual stimuli in environment7 "#$lanations red%ce fear( $ncourage use of radios, tapes, and talking books7 Di+ersional acti+ities s o%ld be enco%raged( Radio and tele+ision increase a)areness of day and ti&e( Remove environmental barriers to ensure safety7 If f%rnit%re or )astebaskets are &o+ed' notify $atient of c anges( 9;D
Discourage doors from being left partially open7 !%lly o$en or closed doors red%ce t e risk for in,%ry a&ong t e +ision:i&$aired( 2aintain bed in lo, position ,it# side rails up, if appropriate7 Side rails el$ re&ind $atient not to get %$ )it o%t el$ ) en needed( 6eep bed in locked position7 T is $re+ent falls(
(uide patient ,#en ambulating, if appropriate7 Describe ,#ere you are ,alking< identify obstacles7 %nstruct patient to #old bot# arms of c#air before sitting and to feel for t#e seat on c#airs or sofas ,it#out arms7 T ese red%ce t e risk of falls( Consult occupational t#erapy staff for assistive devices and training in t#eir use7 Supervise patient ,#en smoking7 S%$er+ision $re+ents accidental fires(
%nvolve caregiver in patientBs care and instructions7 /el$ $atient %nderstand nat%re and li&itations of disease( 4atient and fa&ily need infor&ation to $lan strategies for assisting t e +is%ally i&$aired $atient to co$e(
Reinforce p#ysicianBs e!planation of medical management and surgical procedures, if any7 "eac# general eye care
2aintain sterility of all eye droppers, tubes of medications, and ot#er items7 T is red%ces t e risk of eye infection( Do not s#are eye makeup7 Care for contact lenses as recommended by manufacturer7 Do not rub eyes7
Demonstrate t#e proper administration of eye drops or ointments< allo, for return demonstration by patient and/or caregiver7 )elp family or caregiver identify and make arrangements at #ome7 T ese $ro+ide for $atient<s safety and sense of inde$endence' as indicated( 2ake appropriate referrals to #ome #ealt# agency for nursing and social service follo,+ up7 9;E
Reinforce need to use community agencies, if indicated (e7g7, 5ig#t#ouse for t#e 'lind @c#eck local listingsA or American Foundation for t#e 'lind, 9= 4est 9Ct# Street, .e, Lork, .L 9::99)7
Urinary Retention

-rinary Continence -rinary $limination %nfection Status
9;F
-rinary Retention Care
NANDA Definition: %ncomplete emptying of t#e bladder -rinary retention may occur in con&unction ,it# or independent of urinary incontinence7 -rinary retention is t#e inability to empty t#e bladder even t#oug# urine is present, t#is may occur as a side effect of certain medications, including anest#etic agents, anti#ypertensives, anti#istamines, antispasmodics, and antic#olinergics7 "#ese drugs interfere ,it# t#e nerve impulses necessary to cause rela!ation of t#e sp#incters, ,#ic# allo, urination7 0bstruction of outflo, is anot#er cause of urinary retention7 2ost commonly, t#is type of obstruction in men is t#e result of benign prostatic #ypertrop#y7
Defining C aracteristics: Decreased (M>: ml/#r) or absent urinary output for ; consecutive #ours Fre/uency )esitancy -rgency 5o,er abdominal distention Abdominal discomfort Dribbling
Related !actors: )ig# uret#ral pressures caused by disease, in&ury, or edema (eneral anest#esia Regional anest#esia *ain, fear of pain %nfection %nade/uate intake -ret#ral blockage
"#$ected O%tco&es: *atient empties bladder completely7
9>:
Ongoing Assess&ent
$valuate time intervals bet,een voidings and record t#e amount voided eac# time7 Gee$ing an o%rly log for AB o%rs gi+es a clear $ict%re of t e $atient<s +oiding $attern and a&o%nts' and can el$ to establis a toileting sc ed%le(
Cat#eteri1e and measure residual urine if incomplete emptying is suspected7 Retention of %rine in t e bladder $redis$oses t at $atient to %rinary tract infection and &ay indicate t e need for an inter&ittent cat eteri7ation $rogra&(
Assess amount, fre/uency, and c#aracter (e7g7, color, odor, and specific gravity) of urine7 Determine balance bet,een intake and output7 %ntake greater t#an output may indicate retention7 2onitor urinalysis, urine culture, and sensitivity7 Urinary tract infection can ca%se retention b%t is &ore likely to ca%se fre*%ency( %f ind,elling cat#eter is in place, assess for patency and kinking7 2onitor blood urea nitrogen ('-.) and creatinine7 T is )ill differentiate bet)een %rinary retention and renal fail%re(

%nitiate t#e follo,ing met#ods $ncourage fluids7 Unless &edically contraindicated' fl%id intake s o%ld be at $ncourage intake of cranberry &uice daily7 T is kee$s %rine acidic( T is el$s
least ;>11 &l30A o%rs(
$re+ent infection beca%se cranberry ,%ice &etaboli7es to i$$%ric acid' ) ic &aintains an acidic %rine; acidic %rine is less likely to beco&e infected(

*lace bedpan, urinal, or bedside commode ,it#in reac#7 *rovide privacy7 $ncourage patient to void at least every ? #ours7 )ave patient listen to sound of running ,ater, or place #ands in ,arm ,ater 0ffer fluids before voiding7
and/or pour ,arm ,ater over perineum7 T is sti&%lates %rination(
9>9
*erform CredNBs met#od over bladder7 CredM<s &et od -$ressing do)n o+er t e
bladder )it t e ands. increases bladder $ress%re' and t is in t%rn &ay sti&%late rela#ation of s$ incter to allo) +oiding( T ese facilitate +oiding(
$ncourage patient to take bet#anec#ol (-rec#oline) as ordered7 T is sti&%lates
$arasy&$at etic ner+o%s syste& to release acetylc oline at ner+e endings and to increase tone and a&$lit%de of contractions of s&oot &%scles of %rinary bladder( Side effects are rare after oral ad&inistration of t era$e%tic dose( In s&all s%bc%taneo%s doses' side effects &ay incl%de abdo&inal cra&$s' s)eating' and fl%s ing( In larger doses t ey &ay incl%de &alaise' eadac e' diarr ea' na%sea' +o&iting' ast &atic attacks' bradycardia' lo)ered blood $ress%re -@4.' atrio: +entric%lar block' and cardiac arrest(
%nstitute intermittent cat#eteri1ation7 @eca%se &any ca%ses of %rinary retention are %nsert ind,elling (Foley) cat#eter as ordered "ape cat#eter to abdomen (male)7 T is $re+ents %ret ral fist%la( "ape cat#eter to t#ig# (female)7 T is $re+ents inad+ertent dis$lace&ent(
self:li&ited' t e decision to lea+e an ind)elling cat eter in s o%ld be a+oided(

$ducate patient or caregiver about t#e importance of ade/uate intake, (e7g7, E to 9: %nstruct patient or caregiver on measures to #elp voiding (as described above)7 %nstruct patient or caregiver on signs and symptoms of over+distended bladder (e7g7,
glasses of fluids daily)7

decreased or absent urine, fre/uency, #esitancy, urgency, lo,er abdominal distention, or discomfort)7
%nstruct patient or caregiver on signs and symptoms of urinary tract infection (e7g7, c#ills "eac# patient or caregiver to perform meatal care t,ice daily ,it# soap and ,ater and
and fever, fre/uent urination or concentrated urine, and abdominal or back pain)7
dry t#oroug#ly7 T is red%ces t e risk of infection(
9>;
"eac# patient to ac#ieve an uprig#t position on toilet if possible7 T is is t e nat%ral
$osition for +oiding' and %tili7es t e force of gra+ity(
Ineffecti+e Tiss%e 4erf%sion: 4eri$ eral' Renal' Gastrointestinal' Cardio$%l&onary' Cerebral

NOC O%tco&es -N%rsing O%tco&es Classification.
S%ggested NOC 8abels "issue *erfusion Cardiopulmonary "issue *erfusion Cerebral "issue *erfusion Abdominal 0rgans "issue *erfusion *erip#eral 9>>
Fluid 'alance
$lectrolyte and Acid/'ase 'alance

Circulatory Care Cardiac Care Acute Cerebral *erfusion *romotion
NANDA Definition: Decrease resulting in t#e failure to nouris# t#e tissues at t#e capillary level Reduced arterial blood flo, causes decreased nutrition and o!ygenation at t#e cellular level7 2anagement is directed at removing vasoconstricting factor(s), improving perip#eral blood flo,, and reducing metabolic demands on t#e body7 Decreased tissue perfusion can be transient ,it# fe, or minimal conse/uences to t#e #ealt# of t#e patient7 %f t#e decreased perfusion is acute and protracted, it can #ave devastating effects on t#e patient7 Diminis#ed tissue perfusion, ,#ic# is c#ronic in nature, invariably results in tissue or organ damage or deat#7 "#is care plan focuses on problems in #ospitali1ed patients7 Defining C aracteristics:
*erip#eral
Differences in blood pressure ('*) in opposite e!tremities 4eak or absent perip#eral $dema .umbness, pain, ac#e in

Cool e!tremities Dependent rubor Clammy skin 2ottling *rolonged capillary refill
pulses

e!tremities

Cardiopulmonary
Abnormal arterial blood gases (A'(s)
9>?
"ac#ycardia Dysr#yt#mias )ypotension
"ac#ypnea Angina
Cerebral

Restlessness Confusion 5et#argy Sei1ure activity Decreased (lasgo, Coma Scale scores *upillary c#anges Decreased reaction to lig#t Altered blood pressure )ematuria Decreased urine output (M>: ml/#r) $levated '-./creatinine ratio Decreased or absent bo,el sounds .ausea Abdominal distention/pain
Renal

(astrointestinal

Related !actors:
*erip#eral

%nd,elling arterial cat#eters Constricting cast Compartment syndrome $mbolism or t#rombus Arterial spasm 3asoconstriction
9>=
*ositioning *ulmonary embolism 5o, #emoglobin 2yocardial isc#emia 3asospasm )ypovolemia %ncreased intracranial pressure (%C*) 3asoconstriction %ntracranial bleeding Cerebral edema C#emical irritants )ypovolemia Reduced arterial flo, )emolysis )ypovolemia 0bstruction Reduced arterial flo,
Cardiopulmonary

Cerebral

Renal

(astrointestinal

"#$ected O%tco&e: *atient maintains optimal tissue perfusion to vital organs, as evidenced by strong perip#eral pulses, normal A'(s, alert 50C, and absence of c#est pain7 Ongoing Assess&ent
Assess for signs of decreased tissue perfusion (see Defining C#aracteristics for eac# category in t#is care plan)7 Assess for possible causative factors related to temporarily impaired arterial blood flo,7 "arly detection of ca%se facilitates $ro&$t' effecti+e treat&ent( 9>C
2onitor international normali1ed ratio (%.R) and prot#rombin time/partial t#romboplastin time (*"/*"") if anticoagulants are used for treatment7 @lood clotting st%dies are %sed to deter&ine or ens%re t at clotting factors re&ain )it in t era$e%tic le+els(
2onitor /uality of all pulses7 Assess&ent is needed for ongoing co&$arisons; loss of $eri$ eral $%lses &%st be re$orted or treated i&&ediately(
2aintain optimal cardiac output7 T is ens%res ade*%ate $erf%sion of +ital organs( S%$$ort &ay be re*%ired to facilitate $eri$ eral circ%lation -e(g(' ele+ation of affected li&b' antie&bolis& de+ices.(
Assist ,it# diagnostic testing as indicated7 Do$$ler flo) st%dies or angiogra&s &ay be re*%ired for acc%rate diagnosis( Anticipate need for possible embolectomy, #eparini1ation, vasodilator t#erapy, t#rombolytic t#erapy, and fluid rescue7 T ese facilitate $erf%sion ) en obstr%ction to blood flo) e#ists or ) en $erf%sion as dro$$ed to s%c a dangero%s le+el t at isc e&ic da&age )o%ld be ine+itable )it o%t treat&ent(
S$ecific Inter+entions 4eri$ eral
6eep cannulated e!tremity still7 -se soft restraints or arm boards as needed7 6o+e&ent &ay ca%se tra%&a to artery( Do passive range+of+motion (R02) e!ercises to unaffected e!tremity every ; to ? #ours7 "#ercise $re+ents +eno%s stasis( Anticipate or continue anticoagulation as ordered7 T era$y &ay range fro& intra+eno%s -I5. e$arin' s%bc%taneo%s e$arin' and oral anticoag%lants to anti$latelet dr%gs(
*repare for removal of arterial cat#eter as needed7 Circ%lation is $otentially co&$ro&ised )it a cann%la( It s o%ld be re&o+ed as soon as t era$e%tically safe(
9>D
%f compartment syndrome is suspected, prepare for surgical intervention (e7g7, fasciotomy)7 T e facial co+ering o+er &%scles is relati+ely %nyielding( @lood flo) to tiss%es can beco&e dangero%sly red%ced as tiss%es s)ell in res$onse to tra%&a fro& t e fract%re(
%f cast causes altered tissue perfusion, anticipate t#at p#ysician ,ill bivalve t#e cast or remove it7 T is restores $erf%sion in affected e#tre&ity( Administer o!ygen as needed7 T is sat%rates circ%lating e&oglobin and increases t e effecti+eness of blood t at is reac ing t e isc e&ic tiss%es( *osition properly7 T is $ro&otes o$ti&al l%ng +entilation and $erf%sion( T e $atient )ill e#$erience o$ti&al l%ng e#$ansion in %$rig t $osition( Report c#anges in A'(s (e7g7, #ypo!emia, metabolic acidosis, #ypercapnia)7 "itrate medications to treat acidosis< administer o!ygen as needed7 T is &aintains &a#i&al o#ygenation and ion balance and red%ces syste&ic effects of $oor $erf%sion(
Anticipate and institute anticoagulation as prescribed7 T is red%ces t e risk of t ro&b%s( %nstitute continuous pulse o!imetry and titrate o!ygen administered7 T is &aintains ade*%ate o#ygen sat%ration of arterial blood( Cardio+asc%lar
Administer nitroglycerin (."() sublingually for complaints of angina7 T is i&$ro+es &yocardial $erf%sion( Administer o!ygen as ordered7 Cerebral
$nsure proper functioning of intracranial pressure (%C*) cat#eter (if present)7 %f %C* is increased, elevate #ead of bed >: to ?= degrees7 T is $ro&otes +eno%s o%tflo) fro& brain and el$s red%ce $ress%re( Avoid measures t#at may trigger increased %C* (e7g7, straining, strenuous coug#ing, positioning ,it# neck in fle!ion, #ead flat)7 Increased intracranial $ress%res )ill f%rt er red%ce cerebral blood flo)( 9>E
Administer anticonvulsants as needed7 T ese red%ce risk of sei7%re' ) ic &ay res%lt fro& cerebral ede&a or isc e&ia( Reorient to environment as needed7 Decreased cerebral blood flo) or cerebral ede&a &ay res%lt in c anges in t e 8OC(

$!plain all procedures and e/uipment to t#e patient7 %nstruct t#e patient to inform t#e nurse immediately if symptoms of decreased perfusion persist, increase or return (see Defining C#aracteristics of t#is care plan)7 *rovide information on normal tissue perfusion and possible causes for impairment7
I&$aired 5erbal Co&&%nication


Communication $!pressive Ability Communication Receptive Ability %nformation *rocessing

Active 5istening Communication $n#ancement )earing Deficit Communication $n#ancement Speec# Deficit
9>F
NANDA Definition: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols )uman communication takes many forms7 *ersons communicate verbally t#roug# t#e vocali1ation of a system of sounds t#at #as been formali1ed into a language7 "#ey communicate using body movements to supplement, emp#asi1e, or even alter ,#at is being verbally communicated7 %n some cases, suc# as American Sign 5anguage (t#e formal language of t#e deaf community) or Signed $nglis#, communication is conducted entirely t#roug# #and gestures t#at may or may not be accompanied by body movements and pantomime7 5anguage can be read by ,atc#ing an individualBs lips to observe ,ords as t#ey are s#aped7 )umans communicate t#roug# touc#, intuition, ,ritten means, art, and sometimes a combination of all of t#e mec#anisms listed above7 Communication implies t#e sending of information as ,ell as t#e receiving of information7 4#en communication is received it ceases to be t#e sole product of t#e sender as t#e entire e!periential #istory of t#e receiver takes over and interprets t#e information sent7 At its best, effective communication involves a dialogue t#at not only involves t#e transmission of information but also clarification of points made, e!pansion of ideas and concepts, and e!ploration of factors t#at fall out of t#e original t#oug#ts transmitted7 Communication is a multifaceted, kinetic, reciprocal process7 Communication may be impaired for any number of reasons, but rarely are all avenues for communication compromised at one time7 "#e task for t#e nurse, ,#et#er encountering t#e patient in t#e #ospital or in t#e community, becomes recogni1ing ,#en communication #as become ineffective and t#en using strategies to improve transmission of information7 Defining C aracteristics:

%nability to find, recogni1e, or understand ,ords Difficulty vocali1ing ,ords %nability to recall familiar ,ords, p#rases, or names of kno,n persons, ob&ects, and places -nable to speak dominant language *roblems in receiving t#e type of sensory input being sent or sending t#e type of input necessary for understanding
9?:
Related !actors:
'rain in&ury t#at adversely affects t#e transmission, reception or interpretation of language or ot#er forms of communication Structural problem (e7g7, cleft palate, laryngectomy, trac#eostomy, intubation, or ,ired &a,s) Cultural difference (e7g7, speaks different language) Dyspnea Fatigue Sensory c#allenge involving #earing or vision "#$ected O%tco&es:
*atient is able to use a form of communication to get needs met and to relate effectively ,it# persons and #is or #er environment7
Ongoing Assess&ent

Assess t#e follo,ing "#e patientBs primary and preferred means of communication (e7g7, verbal, ,ritten, gestures)7 Ability to understand spoken ,ord7 It is i&$ortant for ealt care )orkers to %nderstand t at t e constr%ct of gest%red lang%age as an entirely different str%ct%re fro& +erbal and )ritten "nglis ( Signed "nglis is not t e tr%e lang%age of t e deaf co&&%nity b%t an instr%ctional &ec anis& de+elo$ed to teac it t e str%ct%re of "nglis so t at indi+id%als )it earing i&$air&ents &ay read and )rite it( So&e &e&bers of t e deaf co&&%nity learn to do so effecti+ely( A&erican Sign 8ang%age is t e tr%e lang%age of t e deaf co&&%nity( U(S( federal la) re*%ires t e %se of an official inter$reter to co&&%nicate )it $ersons ) o c oose to recei+e infor&ed consent and ot er i&$ortant &edical infor&ation in t eir o)n lang%age(
"#e patientBs preferred language for verbal and ,ritten communication7 4atients &ay s$eak a lang%age *%ite )ell )it o%t being able to read it effecti+ely( Disc arge self: care and follo):%$ infor&ation &%st be co&&%nicated and reinforced )it )ritten 9?9
infor&ation t at t e $atient can %se( T e n%rse can no longer ass%&e t at it is t e $atient<s res$onsibility to gras$ t e infor&ation t at is being $ro+ided( In recognition of t e +ast array of c%lt%res and $ ysical c allenges t at $atients face' it is t e n%rse<s res$onsibility to co&&%nicate effecti+ely(
Ability to understand ,ritten ,ords, pictures, gestures7 In so&e cases t e only )ay to be certain t at co&&%nication as been effecti+e is to arrange for a certified inter$reter to +alidate infor&ation fro& bot sides of t e dialog%e(
Assess conditions or situations t#at may #inder t#e patientBs ability to use or understand language, suc# as t#e follo,ing
Alternate air,ay (e7g7, trac#eostomy, oral or nasal intubation)7 W en air does not $ass o+er +ocal cords' so%nds are not $rod%ced( 0rofacial/ma!illary problems (e7g7, ,ired &a,s)7 Words are artic%lated by coordinated &o+e&ent of &o%t and tong%e; ) en &o+e&ent is i&$inged' co&&%nication &ay be ineffecti+e(
Assess for presence of e!pressive ap#asia (inability to convey information verbally) and receptive ap#asia (i7e7, ,ord meaning may be scrambled during t#e processing of information by t#e patientBs brain)7
Assess for presence and #istory of dyspnea7 4atients ) o are e#$eriencing breat ing $roble&s &ay red%ce or cease +erbal co&&%nication t at &ay co&$licate t eir res$iratory efforts(
Assess energy level7 !atig%e and3or s ortness of breat can &ake co&&%nication diffic%lt or i&$ossible( Assess kno,ledge of patientBs, familyBs, or caregiverBs understanding of sign language, as appropriate7 Indi+id%als ) o a+e no for&al training in sign lang%age %s%ally de+elo$ &ec anis&s for co&&%nication; b%t since co&&%nication is s%c a critical as$ect of e+eryone<s life' consider for&al training for $atient and caregi+ers to en ance co&&%nication(
9?;
Assist t#e patient in seeking an evaluation of #is or #er #ome and ,ork settings7 T is )ill e+al%ate t e need for t ings s%c as assisti+e de+ices' talking co&$%ters' tele$ one ty$ing de+ice' and inter$reters(
Anticipate patient needs and pay attention to nonverbal cues7 T e n%rse s o%ld set aside eno%g ti&e to attend to all of t e details of $atient care( Care &eas%res &ay take longer to co&$lete in t e $resence of a co&&%nication deficit(
*lace important ob&ects ,it#in reac#7 T is &a#i&i7es $atient<s sense of inde$endence( *rovide alternate means of communication for times ,#en interpreters are not available (e7g7, a p#one contact ,#o can interpret t#e patientBs needs)7 $ncourage patientBs attempts to communicate< praise attempts and ac#ievements7 5isten attentively ,#en patient attempts to communicate7 Clarify your understanding of t#e patientBs communication ,it# t#e patient or an interpreter7 .ever talk in front of patient as t#oug# #e or s#e compre#ends not#ing7 T is )ill $re+ent increasing t e $atient<s sense of fr%stration and feelings of el$lessness( 6eep distractions suc# as television and radio at a minimum ,#en talking to patient7 T is )ill kee$ $atient foc%sed' decrease sti&%li going to t e brain for inter$retation' and en ance t e n%rse<s ability to listen(
Do not speak loudly unless patient is #earing+impaired7 8o%d talking does not i&$ro+e t e $atient<s ability to %nderstand if t e barriers are $ri&ary lang%age' a$ asia' or a sensory deficit(
2aintain eye contact ,it# patient ,#en speaking7 Stand close, ,it#in patientBs line of vision (generally midline)7 4atients &ay a+e defect in field of +ision or &ay need to see t e n%rse<s face or li$s to en ance %nderstanding of ) at is being co&&%nicated(
(ive t#e patient ample time to respond7 It &ay be diffic%lt for $atients to res$ond %nder $ress%re; t ey &ay need e#tra ti&e to organi7e res$onses' find t e correct )ord' or &ake necessary lang%age translations(
9?>
*raise patientBs accomplis#ments7 Ackno,ledge #is or #er frustrations7 T e inability to co&&%nicate en ances a $atient<s sense of isolation and &ay $ro&ote a sense of el$lessness(
%f t#e patientBs ability to speak is limited to yes and no ans,ers, try to p#rase /uestions so t#at t#e patient can use t#ese responses7 -se s#ort sentences and ask only one /uestion at a time7 T is allo)s t e $atient to stay foc%sed on one t o%g t( Speak slo,ly and distinctly, repeating key ,ords to prevent confusion7 Supplement verbal communication ,it# meaningful gestures7 T is $ro+ides t e $atient )it &ore c annels t ro%g ) ic infor&ation can be co&&%nicated(
(ive concrete directions t#at t#e patient is p#ysically capable of doing (e7g7, Gpoint to t#e pain,G Gopen your mout#,G and Gturn your #eadG)7 Avoid finis#ing sentences for t#e patient7 Allo, t#e patient to complete #is or #er sentence and t#oug#t< but if t#e patient appears to be #aving difficulty, ask t#e patient for permission to #elp t#em7 Say t#e ,ord or p#rase slo,ly and distinctly if #elp is re/uested7 'e calm and accepting during attempts< do not say you understand if you do not7 T is &ay increase fr%stration and decrease t e $atient<s tr%st in yo%(
4#en patient #as difficulty ,it# verbal e!pressions, support t#e ,ork t#e patient is doing in speec# t#erapy by providing practice sessions often t#roug#out t#e day7 'egin ,it# simple ,ords (e7g7, Gyes,G Gno,G Gt#is is a cupG), t#en progress7
4#en patient cannot identify ob&ects by name, give practice in receiving ,ord images (e7g7, point to an ob&ect and clearly enunciate its name GcupG or GpenG)7 Correct errors7 Not correcting errors reinforces %ndesirable $erfor&ance' and )ill &ake correction &ore diffic%lt later( *rovide a list of ,ords patient can say< add ne, ,ords to it7 S#are t#is list ,it# family, significant ot#ers, and ot#er care providers7 T is broadens t e gro%$ of $eo$le )it ) o& t e $atient can co&&%nicate(
*rovide patient ,it# ,ord+and+p#rase cards, ,riting pad and pencil, or picture board7 T is is es$ecially el$f%l for int%bated and trac eal $atients or t ose ) ose ,a)s are )ired(
9??
Carry on a one+,ay conversation ,it# a totally ap#asic patient7 It &ay not be $ossible to deter&ine ) at infor&ation is %nderstood by t e $atient' b%t it s o%ld not be ass%&ed t at t e $atient %nderstands not ing abo%t is or er en+iron&ent(
Consult a speec# t#erapist for additional #elp7 See t#at patient is ,ell+rested before eac# session ,it# t#e speec# t#erapist7 !atig%e &ay a+e an ad+erse effect on learning ability(
Consider use of electronic speec# generator in postlaryngectomy patients7
%nform patient, significant ot#er, or caregiver of t#e type of ap#asia t#e patient #as and #o, it affects speec#, language skills, and understanding7 6any fa&ily &e&bers ass%&e t at a $atient<s &entation as been affected by a brain in,%ry; t is &ay or &ay not be tr%e' and if tr%e' so&e of t e effects &ay be a&enable to re&ediation(
0ffer significant ot#ers t#e opportunity to ask /uestions about patientBs communication problem7 It is i&$ortant for t e fa&ily to kno) t at t ere are &any )ays to send infor&ation to so&eone and t at ti&e &ay be needed to %nderstand t e s$ecial needs of t e $atient(
*rovide ans,ers and #elpful suggestions for ,#at is kno,n ,#ile not providing false assurances7 $ncourage family member/caregiver to talk to patient even t#oug# patient may not respond7 T is decreases $atient<s sense of isolation and &ay assist in reco+ery fro& a$ asia(
$ncourage patient to sociali1e ,it# family and friends7 Co&&%nication s o%ld be enco%raged des$ite i&$air&ent( $!plain t#at brain in&ury decreases attention span7 Suggest t#at t#e family engage t#e patient often t#roug#out t#e day for s#ort periods7 $ncourage t#e family to look for cues t#at t#e patient is overstimulated or fatigued7 *rovide patient ,it# an appointment ,it# a speec# t#erapist, if not already done7 %nform patient and significant ot#ers to seek information about ap#asia from t#e American Speec#+5anguage+)earing Association, 9:E9: Rock,ell *ike, Rockville, 2D ;:E=;7 9?=
Deaf patients and t#eir families s#ould be referred to t#eir local #earing society for community support, education, and sign language training7
"#cess !l%id 5ol%&e

/y$er+ole&ia; !l%id O+erload NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels
Fluid 'alance

Fluid 2onitoring Fluid 2anagement
NANDA Definition: %ncreased isotonic fluid retention Fluid volume e!cess, or #ypervolemia, occurs from an increase in total body sodium content and an increase in total body ,ater7 "#is fluid e!cess usually results from compromised regulatory mec#anisms for sodium and ,ater as seen in congestive #eart failure (C)F), kidney failure, and liver failure7 %t may also be caused by e!cessive intake of sodium from foods, intravenous (%3) solutions, medications, or diagnostic contrast dyes7 )ypervolemia may be an acute or c#ronic condition managed in t#e #ospital, outpatient center, or #ome setting7 "#e t#erapeutic goal is to treat t#e underlying disorder and return t#e e!tracellular fluid compartment to normal7 "reatment consists of fluid and sodium restriction, and t#e use of diuretics7 For acute cases dialysis may be re/uired7 Defining C aracteristics:
4eig#t gain 9?C
$dema 'ounding pulses S#ortness of breat#< ort#opnea *ulmonary congestion on !+ray Abnormal breat# sounds crackles (rales) C#ange in respiratory pattern "#ird #eart sound (S>) %ntake greater t#an output Decreased #emoglobin or #ematocrit %ncreased blood pressure %ncreased central venous pressure (C3*) %ncreased pulmonary artery pressure (*A*) Jugular vein distension C#ange in mental status (let#argy or confusion) 0liguria Specific gravity c#anges A1otemia C#ange in electrolytes Restlessness and an!iety Related !actors
$!cessive fluid intake $!cessive sodium intake Renal insufficiency or failure Steroid t#erapy 5o, protein intake or malnutrition Decreased cardiac output< c#ronic or acute #eart disease )ead in&ury 5iver disease Severe stress )ormonal disturbances 9?D
"#$ected O%tco&es: *atient maintains ade/uate fluid volume and electrolyte balance as evidenced by vital signs ,it#in normal limits, clear lung sounds, pulmonary congestion absent on !+ray, and resolution of edema7 Ongoing Assess&ent
0btain patient #istory to ascertain t#e probable cause of t#e fluid disturbance7 T is can el$ to g%ide inter+entions( 6ay incl%de increased fl%ids or sodi%& intake' or co&$ro&ised reg%latory &ec anis&s(
Assess or instruct patient to monitor ,eig#t daily and consistently, ,it# same scale and preferably at t#e same time of day7 Instr%ction facilitates acc%rate &eas%re&ent and el$s to follo) trends(
2onitor for a significant ,eig#t c#ange (; pounds) in 9 day7 $valuate ,eig#t in relation to nutritional status7 In so&e eart fail%re $atients' )eig t &ay be a $oor indicator of fl%id +ol%&e stat%s( 4oor n%trition and decreased a$$etite o+er ti&e res%lt in a decrease in )eig t' ) ic &ay be acco&$anied by fl%id retention e+en t o%g t e net )eig t re&ains %nc anged(
%f patient is on fluid restriction, revie, daily log or c#art for recorded intake7 4atients s o%ld be re&inded to incl%de ite&s t at are li*%id at roo& te&$erat%re s%c as Nell:O' s erbet' and 4o$sicles(
2onitor and document vital signs7 Sin%s tac ycardia and increased blood $ress%re are seen in early stages( "lderly $atients a+e red%ced res$onse to catec ola&ines' t %s t eir res$onse to fl%id o+erload &ay be bl%nted' )it less rise in eart rate(
2onitor for distended neck veins and ascites7 2onitor abdominal girt# to follo, any ascites accurately7 Auscultate for a t#ird sound, and assess for bounding perip#eral pulses7 T ese are signs of fl%id o+erload( Assess for crackles in lungs, c#anges in respiratory pattern, s#ortness of breat#, and ort#opnea7 T ese are early signs of $%l&onary congestion( Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum7 4itting ede&a is &anifested by a de$ression t at re&ains after one<s finger is $ressed o+er an ede&ato%s area and t en re&o+ed( Grade ede&a fro& trace -indicating barely
9?E
$erce$tible. to A -se+ere ede&a.( 6eas%re&ent of an e#tre&ity )it a &eas%ring ta$e is anot er &et od of follo)ing ede&a(
2onitor c#est !+ray reports7 As interstitial ede&a acc%&%lates' t e #:rays s o) clo%dy ) ite l%ng fields( 2onitor input and output closely7 Alt o%g o+erall fl%id intake &ay be ade*%ate' s ifting of fl%id o%t of t e intra+asc%lar to t e e#tra+asc%lar s$aces &ay res%lt in de ydration( T e risk of t is occ%rring increases ) en di%retics are gi+en( 4atients &ay %se diaries for o&e assess&ent(
$valuate urine output in response to diuretic t#erapy7 !oc%s is on &onitoring t e res$onse to t e di%retics' rat er t an t e act%al a&o%nt +oided( At o&e' it is %nrealistic to e#$ect $atients to &eas%re eac +oid( T erefore recording t)o +oids +ers%s si# +oids after a di%retic &edication &ay $ro+ide &ore %sef%l infor&ation( NOT": !l%id +ol%&e e#cess in t e abdo&en &ay interfere )it absor$tion of oral di%retic &edications( 6edications &ay need to be gi+en intra+eno%sly by a n%rse in t e o&e or o%t$atient setting(
2onitor for e!cessive response to diuretics ;+pound loss in 9 day, #ypotension, ,eakness, blood urea nitrogen ('-.) elevated out of proportion to serum creatinine level7
2onitor serum electrolytes, urine osmolality, and urine+specific gravity7 Assess t#e need for an ind,elling urinary cat#eter7 Treat&ent foc%ses on di%resis of e#cess fl%id( During t#erapy, monitor for signs of #ypovolemia7 6onitoring $re+ents co&$lications associated )it t era$y( %f #ospitali1ed, monitor #emodynamic status including C3*, *A*, and *C4*, if available7 T is direct &eas%re&ent ser+es as o$ti&al g%ide for t era$y(
%nstitute/instruct patient regarding fluid restrictions as appropriate7 T is el$s red%ce e#tracell%lar +ol%&e( !or so&e $atients' fl%ids &ay need to be restricted to ;111 &l3day(
9?F
*rovide innovative tec#ni/ues for monitoring fluid allotment at #ome7 For e!ample, suggest t#at patients measure out and pour into a large pitc#er t#e prescribed daily fluid allo,ance (e7g7, 9::: ml)< t#en every time patient drinks some fluid, #e or s#e is to remove t#at amount from t#e pitc#er7 T is $ro+ides a +is%al g%ide for o) &%c fl%id is still allo)ed t ro%g o%t t e day(
Restrict sodium intake as prescribed7 Sodi%& diets of 0 to 2 g are %s%ally $rescribed( Administer or instruct patient to take diuretics as prescribed7 Di%retic t era$y &ay incl%de se+eral different ty$es of agents for o$ti&al t era$y' de$ending on t e ac%teness or c ronicity of t e $roble&( !or c ronic $atients' co&$liance is often diffic%lt for $atients trying to &aintain a nor&al lifestyle(
%nstruct patient to avoid medications t#at may cause fluid retention, suc# as over+t#e+ counter nonsteroidal antiinflammatory agents, certain vasodilators, and steroids7 $levate edematous e!tremities7 T is increases +eno%s ret%rn and' in t%rn' decreases ede&a( Reduce constriction of vessels (e7g7, use appropriate garments, avoid crossing of legs or ankles)7 T is $re+ents +eno%s $ooling( %nstruct in need for antiembolic stockings or bandages as ordered7 T ese el$ $ro&ote +eno%s ret%rn and &ini&i7e fl%id acc%&%lation in t e e#tre&ities( *rovide interventions related to specific etiological factors (e7g7, inotropic medications for #eart failure, paracentesis for liver disease)7 !or ac%te $atients:
Consider admission to acute care setting for #emofiltration or ultrafiltration7 T is is a +ery effecti+e &et od to dra) off e#cess fl%id( Collaborate ,it# t#e p#armacist to ma!imally concentrate %3s and medications7 T is decreases %nnecessary fl%ids(
Apply saline lock on %3 line7 T is &aintains $atency b%t decreases fl%id deli+ered to $atient in a 0A: o%r $eriod( Administer %3 fluids t#roug# infusion pump, if possible7 T is ens%res acc%rate deli+ery of I5 fl%ids(
9=:
Assist ,it# repositioning every ; #ours if patient is not mobile7 T is $re+ents fl%id acc%&%lation in de$endent areas(

"eac# causes of fluid volume e!cess and/or e!cess intake to patient or caregiver7 *rovide information as needed regarding t#e individualBs medical diagnosis (e7g7, congestive #eart failure @C)FA, renal failure)7 $!plain or reinforce rationale and intended effect of treatment program7 %dentify signs and symptoms of fluid volume e!cess7 $!plain importance of maintaining proper nutrition and #ydration, and diet modifications7 %dentify symptoms to be reported7
9=9

119663657-Nursing Diagnosis Care Plans

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

119663657-Nursing Diagnosis Care Plans

Transféré par

Droits d'auteur :

Formats disponibles

NURSING DIAGNOSIS

Ineffective air+ay clearance..................................................................1,

Risk for As&iration.................................................................................21

Decrease! Car!iac O't&'t....................................................................24

Ineffective 5reat%in# 6attern................................................................*2

Dist'rbe! 5o!y I$a#e...........................................................................*0

Diarr%ea 7oose Stools8 Clostri!i'$ !ifficile -C. !ifficile..................................,/

Deficient 9l'i! :ol'$e ;y&ovole$ia De%y!ration............................................................../"

I$&aire! Gas (2c%an#e :entilation or 6erf'sion I$balance................................................../,

Ineffective ;ealt% <aintenance............................................................./1

I$&aire! 6%ysical <obility I$$obility........................................................................................34

Nonco$&liance =no+le!#e Deficit 6atient (!'cation..............................................0*

I$balance! N'trition> <ore t%an 5o!y Re?'ire$ents Obesity Over+ei#%t........................................................................41

Self@Care Deficit 5at%in#);y#iene Dressin#)Groo$in# 9ee!in# Toiletin#...............11

Dist'rbe! Slee& 6attern Inso$nia........................................................................................111

Ineffective T%era&e'tic Re#i$en <ana#e$ent...................................11/

Dist'rbe! Sensory 6erce&tion> A'!itory ;earin# 7oss ;earin# I$&aire! Deafness....................................111

Dist'rbe! Sensory 6erce&tion> :is'al :ision 7oss <ac'lar De#eneration 5lin!ness..............................12,

Ineffective Tiss'e 6erf'sion> 6eri&%eral8 Renal8 Gastrointestinal8 Car!io&'l$onary8 Cerebral.........................................................................................1**

I$&aire! :erbal Co$$'nication.........................................................1*1

(2cess 9l'i! :ol'$e ;y&ervole$ia 9l'i! Overloa!.......................................................1,3

Close &onitoring ser+es as a g%ide for o$ti&al $rogression of acti+ity(

Ineffecti+e air)ay clearance

%f coug# is ineffective, use nasotrac#eal suctioning as needed

%nstruct patient on ,arning signs of pending or recurring pulmonary problems7

Risk for As$iration

Risk Control Risk Detection Respiratory Status 3entilation

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

2onitor s,allo,ing ability

*osition ,it# #ead of bed elevated >: to ?= degrees7

An!iety Reduction *resence Calming "ec#ni/ue $motional Support

%nstruct t#e patient in t#e appropriate use of antian!iety medications7

Decreased Cardiac O%t$%t

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

Cardiac Care )emodynamic Regulation "eac#ing Disease *rocess

2aintain p#ysical and emotional rest, as in t#e follo,ing

Ineffecti+e @reat ing 4attern

Respiratory Status 3entilation

3ital Sign Status

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

Air,ay 2anagement Respiratory 2onitoring

2onitor breat#ing patterns

$ncourage sustained deep breat#s by

Dist%rbed @ody I&age

NOC O%tco&es -N%rsing O%tco&es Classification. S%ggested NOC 8abels

'ody %mage Self+$steem

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

'ody %mage $n#ancement (rief 4ork Facilitation Coping $n#ancement

.ote fre/uency of self+critical remarks7

Coping Decision 2aking %nformation *rocessing

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

'o,el $limination Fluid 'alance ?=

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

Diarr#ea 2anagement $nteral "ube Feeding "eac#ing *rescribed 2edications

Assess #ydration status, as in t#e follo,ing

"eac# patient or caregiver t#e follo,ing measures t#at control diarr#ea

Deficient !l%id 5ol%&e

Fluid 'alance )ydration

NIC Inter+entions -N%rsing Inter+entions Classification. S%ggested NIC 8abels

Fluid 2onitoring Fluid 2anagement Fluid Resuscitation

$ncourage patient to drink prescribed fluid amounts7

"lderly $atients are es$ecially s%sce$tible to fl%id o+erload(

Refer to #ome #ealt# nurse as appropriate7

I&$aired Gas "#c ange

Joint 2obility Fall recautions ositioning 'ed Rest Care

Analgesic Administration Conscious Sedation ain 2anagement atient+Controlled Analgesia Assistance

ressure -lcer revention Skin Surveillance