EXTENDED CARE

Patients in the acute care setting may be discharged to an extended-care facility. Patients requiring relatively short-
term rehabilitation and those needing long-term care/permanent nursing care are included in this group. The level of
care and needs of the patient (e.g., physical, occupational, rehabilitation therapy; IV and respiratory support) are
frequently the deciding factors in the choice of placement. Additionally, visual impairments, memory/mental
impairment, and physical immobility lead to a loss of independence for many individuals. Although elderly people are
the primary population in extended-care facilities, increasing numbers of younger individuals are requiring care for
debilitating conditions when they cannot be managed in the home setting.

RELATED CONCERNS
AIDS
Cancer
Cerebrovascular accident (CVA)/ stroke
Craniocerebral trauma (acute rehabilitative phase)
End of life/hospice care
Multiple sclerosis
Psychosocial aspects of care
Spinal cord injury (acute rehabilitative phase)
Surgical intervention
Ventilatory assistance (mechanical)

Patient Assessment Database

Data depend on underlying physical/psychosocial conditions necessitating continuation of structured care.

TEACHING/LEARNING
Discharge plan Projected mean length of stay:Depends on underlying disease/condition and
individual
considerations: care needs. Therefore, this may be a temporary or permanent placement.
May require assistance with treatments, self-care activities, homemaker/maintenance tasks,
or alternative living arrangements (e.g., group home)
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES (DEPENDENT ON AGE, GENERAL HEALTH, AND MEDICAL

CONDITION)
CBC: Reveals problems such as infection, anemia, other abnormalities.
Chemistry profile: Evaluates general organ function/imbalances. Age-related changes include decreased serum
albumin, up to 20% increase in alkaline phosphatase, decreased urine creatinine clearance.
Urinalysis: Provides information about kidney function; determines presence of UTI or DM. Note: Bacteria is common
in some populations, especially the elderly and bedridden, reflecting urinary stasis.
Pulse oximetry: Determines oxygenation, respiratory function.
Communicable disease screens: To rule out tuberculosis (TB), HIV, venereal disease, hepatitis.
Drug screen: As indicated by usage to identify therapeutic or toxic levels.
Visual acuity testing: Identifies cataracts/other vision problems.
Tonometer test: Measures intraocular pressure.
Chest x-ray: Reveals size of heart, lung abnormalities/disease conditions, changes of the large blood vessels and bony
structure of the chest.
ECG: Provides baseline data; detects abnormalities, e.g., ST-segment and T-wave changes, atrial and ventricular
dysrhythmias, and various heart blocks are common in the elderly.

NURSING PRIORITIES
1. Promote physiological and psychological well-being.
2. Provide for security and safety.
3. Prevent complications of disease and/or aging process.
4. Promote effective coping skills and independence.
5. Encourage continuation of healthy habits, participation in plan of care to meet individual needs and wishes.

DISCHARGE GOALS
1. Patient dealing realistically with current situation.
2. Homeostasis maintained.
3. Injury prevented.
4. Complications prevented/minimized.
5. Patient meeting ADLs by self/with assistance as necessary.
6. Plan in place to meet needs after discharge as appropriate.

NURSING DIAGNOSIS: Anxiety [specify level]/Fear

May be related to
Change in health status, role functioning, interaction patterns, socioeconomic status, environment
Unmet needs; recent life changes, loss of friends/SO
Possibly evidenced by
Apprehension, restlessness, repetitive questioning; pacing, purposeless activity; insomnia
Various behaviors (appears overexcited, withdrawn, worried, fearful); presence of facial tension, trembling,
hand tremors
Expressed concern regarding changes in life events
Focus on self; lack of interest in activity
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Anxiety [or] Fear Control (NOC)
Verbalize understanding of reasons for change, as able.
Demonstrate appropriate range of feelings and lessened fear.
Participate in routine and special/social events as capable.
Verbalize acceptance of situation.

ACTIONS/INTERVENTIONS RATIONALE
Anxiety Reduction (NIC)

Independent
Provide patient/SO with a copy of A Patient’s Bill of
Rights and review it with them. Discuss facility’s rules,
e.g., visitors, off-grounds visits, personal property.
Provides information that can foster confidence that
individual rights do continue in this setting and patient is
still “his or her own person” and has some control over
what happens.

Ascertain whether patient has completed Advance Ensures patient/family wishes will be known to provide
Directives. Provide information as appropriate. direction to caregivers.

Determine patient/SO attitude toward admission to If this is expected to be a temporary placement,

facility and expectations for the future. patient/SO concerns will be different than if placement is
permanent. When patient is giving up own home and way
of life, feelings of helplessness, loss, and grief are to be
expected.
ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
Help family/SO to be honest with patient regarding
admission. Be clear about actions/events.
Identify support person(s) important to patient and
include in care activities, mealtime, and so on, as
appropriate.
Assess level of anxiety and discuss reasons when
possible.
Develop nurse-patient relationship.
Make time to listen to patient about concerns, and
encourage free expression of feelings, e.g., anger,
hostility, fear, and loneliness.
Acknowledge reality of situation and feelings of patient.
Accept expressions of anger while limiting aggressive,
acting-out behavior.
Identify strengths and successful coping behaviors and
incorporate into problem solving.
Orient to physical aspects of facility, schedules, and
activities. Introduce to roommate(s) and staff. Give
explanation of roles.
Determine patient’s usual schedule and incorporate into
facility routine as much as possible.
Provide information in written or taped form as well.
Give careful thought to room placement. Provide help and
encouragement in placing patient’s own belongings
around room. Do not transfer from one room to another
without patient approval/documentable need.
RATIONALE
Family may have difficulty dealing with decision/reality
of permanent placement and may avoid discussing
situation with patient. Honesty decreases “surprises,”
assists in maintaining trust, and may enhance coping.
During adjustment period/times of stress, patient may
benefit from presence of trusted individual who can
provide reassurance and reduce sense of isolation.
Identifying specific problems enables individual to deal
more realistically with them and care provider to
intervene as necessary, e.g., patient who is being
neglected or abused or has unrelieved pain may be very
anxious and afraid or unable to verbalize.
Trusting relationships among patient/SO/staff promote
optimal care and support.
Being available in this way allows patient to feel
accepted, begin to acknowledge and deal with feelings
related to circumstances of admission.
Permission to express feelings allows for beginning
resolution. Acceptance promotes sense of self-worth.
Note: Psychosocial and/or physiological disturbances can
occur as a result of transfer from one environment to
another (i.e., relocation stress syndrome).
Building on past successes increases likelihood of
positive outcome in present situation. Enhances sense of
control and management of current deficits.
Getting acquainted is an important part of admission.
Knowledge of where things are and who patient can
expect assistance from can be helpful in reducing anxiety.
Consistency provides reassurance and may lessen
confusion and enhance cooperation.
Overload of information is difficult to process. Patient
can refer to written or taped material as needed to refresh
memory/learn new information.
Location, roommate compatibility, and place for personal
belongings are important considerations for helping
patient feel “at home.” Changes are often met with
resistance and can result in emotional upset and decline in
physical condition. Note: Persons with severe behavioral
problems/cognitive dysfunctions may require a private
room.
ACTIONS/INTERVENTIONS RATIONALE
Anxiety Reduction (NIC)

Independent
Note behavior, presence of suspiciousness/paranoia,
irritability, defensiveness. Compare with SO’s description
of customary responses.
Increased stress, physical discomfort, and fatigue may
temporarily exacerbate mental deterioration (cognitive
inaccessibility) and further impair communication (social
inaccessibility). This represents a catastrophic episode
that can escalate into a panic state and violence.

Be aware of escalating anxiety, presence of delirium. Common causes of delirium include drug toxicity,
Look for possible causes. electrolyte imbalances, withdrawal states (alcohol, other
drugs), pain/trauma (especially hip fractures), and
advanced disease resulting in organ failure.

Collaborative

Refer to social service or other appropriate agency for Often patient is not aware of the resources available, and
assistance. Have case manager/social worker discuss providing current information about individual
ramifications of Medicare/Medicaid if patient is eligible coverage/limitations and other possible sources of support
for these resources. will assist with adjustment to new situation.

NURSING DIAGNOSIS: Grieving, anticipatory

May be related to
Perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO; cultural
beliefs about aging/debilitation
Possibly evidenced by
Denial of feelings, depression, sorrow, guilt
Alterations in the activity level, sleep patterns, eating habits, libido
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Grief Resolution (NOC)
Identify and express feelings appropriately.
Progress through the grieving process.
Enjoy the present and plan for the future, one day at a time.
ACTIONS/INTERVENTIONS RATIONALE
Grief Work Facilitation (NIC)

Independent
Assess emotional state. Note cultural beliefs, Anxiety and depression are common reactions to
expectations. changes/losses associated with long-term illness or
debilitating condition. In addition, changes in
neurotransmitter levels (e.g., increased monoamine
oxidase [MAO] and serotonin levels with decreased
norepinephrine) may potentiate depression in elderly
patients. Personal expectations may affect response to
change.

Make time to listen to patient. Encourage free expression It is more helpful to allow these feelings to be expressed
of hopeless feelings and desire to die. and dealt with than to deny or ignore them.

Assess suicidal potential. May be related to physical disease, social isolation, and
grief. Note: Studies indicate women are three times as
likely to attempt suicide; however, men are three times as
likely to succeed.

Involve SO in discussions and activities to the level of When SOs are involved, there is more potential for
their willingness. successful problem solving. Note: SO may not be
available or may not choose to be involved.

Provide liberal touching/hugs as individually accepted. Conveys sense of concern/closeness to reduce feelings of
isolation and enhance sense of self-worth. Note: Touch
may be viewed as a threat by some patients and escalate
feelings of agitation/anger.

Identify spiritual concerns. Discuss available resources Search for meaning is common to those facing changes in
and encourage participation in religious activities as life. Participation in religious/spiritual activities can
appropriate. provide sense of direction and peace of mind.

Assist with/plan for specifics as necessary (e.g., Advance Having these issues resolved can help patient/SO deal
Directives to determine code status/Living Will wishes, with the grieving process and may provide peace of mind.
making of will, funeral arrangements if appropriate).

Collaborative

Refer to other resources as indicated, e.g., psychiatric May need further assistance to resolve some problems.
clinical nurse specialist, case manager/social worker,
spiritual advisor.
 NURSING DIAGNOSIS: Thought Processes, disturbed
May be related to
Physiological changes of aging, loss of cells/brain atrophy, decreased blood supply, altered sensory input
Pain; effects of medications
Psychological conflicts: disrupted life pattern
Possibly evidenced by
Slower reaction times, gradual memory loss, altered attention span; disorientation; inability to follow
Altered sleep patterns
Personality changes
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cognitive Ability (NOC)
Maintain usual reality orientation.
Risk Control (NOC)
Recognize changes in thinking and behavior.
Identify interventions to deal effectively with situation/deficits.

ACTIONS/INTERVENTIONS RATIONALE
Cognitive Stimulation (NIC)

Independent
Allow adequate time for patient to respond to questions/ Reaction time may be slowed with aging (changes in
comments and to make decisions. metabolism/cerebral blood flow) or with brain injuries
and some neuromuscular conditions.

Discuss happenings of the past. Place familiar objects in Events of the past may be more readily recalled by the
room. Encourage the display of photographs/photo elderly patient, because long-term memory usually
albums, frequent visits from SO/friends. remains intact. Reminiscence/life review and
companionship are beneficial to patients.

Note presence of short-term memory loss, and provide
with aids (e.g., calendars, clocks, room signs, pictures) to
assist in continual reorientation.
Short-term memory loss presents a challenge for nursing
care, especially if patient cannot remember such things as
how to use the call bell or how to get to the bathroom.
This problem is not in patient’s control but may be less
frustrating if simple reminders are used. It may be helpful
for older person (and family) to know that short-term
memory loss is common and is not necessarily a sign of
“senility.”

Evaluate individual stress level and deal with it Stress level may be greatly increased because of recent
appropriately. losses, e.g., poor health, death of spouse/companion, loss
of home. In addition, some conflicts that occur with age
come from previously unresolved problems that may need
to be dealt with now.
ACTIONS/INTERVENTIONS
Cognitive Stimulation (NIC)
Independent
Assess physical status/psychiatric symptoms. Institute
interventions appropriate to findings.
Reorient to person/place and time as appropriate.
Have patient repeat verbal/written instructions.
Note cyclic changes in mentation/behavior, e.g., evening
confusion, picking at bedclothes, banging on side rails,
pacing, shouting, wandering aimlessly.
Involve in regular exercise, activity, and diversional
programs.
Schedule at least one rest period per day.
Provide brighter lighting in room/area by midafternoon
(e.g., 3 PM) or earlier on cloudy/winter days.
Turn off lights at bedtime. Provide night-lights where
appropriate.
Support patient’s involvement in own care. Provide
opportunity for choices on a daily basis.
Collaborative
Review results of laboratory/diagnostic tests, e.g.,
electrolytes, thyroid studies, rapid plasma reagin (RPR),
full drug screen, computed tomography (CT) scan.
Administer medications as indicated, e.g., tacrine
(Cognex), donepezil (Aricept).
RATIONALE
Not all mental changes are the result of aging, and it is
important to rule out physical causes before accepting
these as unchangeable. May be pain (often
unreported/underestimated), metabolic, toxic, drug-
induced (e.g., antiparkinson agents, tricyclic
antidepressants), or the result of infectious, cardiac, or
respiratory disorders.
Helps patient maintain focus.
Verifies hearing/ability to read and comprehend.
“Sundowner syndrome” may occur in response to
visual/hearing deficits enhanced by declining light,
fatigue, inflexible institution schedules, peak/trough drug
levels, dehydration, and electrolyte imbalances.
Promotes release of endorphins, enhancing sense of well-
being, and can improve thinking abilities. Note: Studies
suggest withdrawn and inactive patients are at greater risk
of evening confusion.
Prevents fatigue; enhances general well-being.
Maximizes visual perception; may limit evening
confusion.
Reinforces “sleep time” while meeting safety needs.
Choice is a necessary component in everyday life.
Cognitively impaired patients may respond with
aggressive behavior as they lose control in their lives.
Aids in establishing cause of changes in mentation and
determining treatment options. Note: The latter four tests
can identify the causes of dementia in 90% of cases.
These drugs may fight dementia by blocking chemical
breakdown of acetylcholine and improving cholinergic
function. Aricept has been shown to improve intellectual
ability and daily functioning in mild to moderate
Alzheimer’s disease (as assessed by Alzheimer’s Disease
Assessment Scale [ADAS-Cog]).
 NURSING DIAGNOSIS: Family Coping, ineffective: compromised
May be related to
Placement of family member in extended-care facility
Temporary family disorganization and role changes
Situational/transitional crises SO may be facing
Patient providing little support for SO
Prolonged disease or disability progression that exhausts the supportive capacity of SOs
Possibly evidenced by
SO describes significant preoccupation with personal reactions, e.g., fear, anticipatory grief, guilt, anxiety
SO attempts assistive/supportive behaviors with unsatisfactory results
SO withdraws from patient
SO displays protective behavior disproportionate (too little or too much) to patient’s abilities/need for autonomy
DESIRED OUTCOMES/EVALUATION CRITERIA—FAMILY WILL:
Family Coping (NOC)
Identify/verbalize resources within themselves to deal with the situation.
Interact appropriately with patient and staff, providing support and assistance as indicated.
Verbalize knowledge and understanding of situation.

ACTIONS/INTERVENTIONS RATIONALE
Family Support (NIC)

Independent
Introduce staff and provide SO with information about Helpful to establish beginning relationships. Offers
facility and care. Be available for questions. Provide tour opportunities for enhancing feelings of involvement.
of facility.

Determine involvement and availability of family/SO. Clarifies expectations and abilities, identifies needs.

Encourage SO participation in care at level of desire and Helps family to feel at ease and allows them to feel
capability and within limits of safety. Include in social supportive and a part of patient’s life.
events/celebrations.

Accept choices of SO regarding level of involvement in Families may choose to ignore patient or may project
care. feelings of guilt regarding placing patient in facility by
criticizing staff. Note: Feelings of dissatisfaction with the
staff may be transferred back to patient.

Evaluate SO’s/caregiver’s level of stress/coping abilities,
especially before planning for discharge.
Caring for/about patients with chronic/debilitating
conditions places a heavy strain on SO. Although support
groups may be very helpful, learning stress management
techniques may be more effective in strengthening
individual coping as the focus is on the SO rather than the
SO-patient relationship.

Support the caregiver with attention, compassion, time, Nursing interventions need to prepare the caregivers for
respect, honesty, advocacy, and understanding. the challenges they face and meet their needs for
compassion and caring.
ACTIONS/INTERVENTIONS RATIONALE
Family Support (NIC)

Independent
Identify availability and use of community support Helps determine areas of need, and provides information
systems. regarding additional resources to enhance coping.

Be aware of caregivers’ own feelings of disapprovaland Group care conferences or individual counseling may be
frustration about patient’s/SO’s choices and goals that helpful in problem solving.
differ from those of staff, and deal with appropriately.

Collaborative

Inform SO of services available to them (meal tickets, Promotes feeling of involvement; eases transition in
family cooking time, group care conference, visiting adjustment to patient’s admission to home care or facility
nurse, caseworker, social services). care.

Advise caregivers of resources available, such as Helps nurses, patients, and caregivers feel supported and
Eldercare Locator, SeniorNet, Today’s Caregiver, able to provide more skillful care.
Caregiver Network, Inc.

NURSING DIAGNOSIS: Poisoning, risk for [drug toxicity]

Risk factors may include
Reduced metabolism; impaired circulation; precarious physiological balance, presence of multiple
diseases/organ involvement
Use of multiple prescribed/OTC drugs
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Medication Response (NOC)
Maintain prescribed drug regimen free of untoward side effects.

ACTIONS/INTERVENTIONS RATIONALE
Medication Management (NIC)

Independent
Determine allergies, medication, and other drug use Helps avoid repetition/creation of problems.
history.

Review resources (e.g., drug manuals, pharmacist) for
information about toxic symptoms and side effects. List
drug actions and interactions and idiosyncracies, e.g.,
medications that are given with or without foods, as well
as those that should not be crushed.
Provides information about drugs being taken and
identifies possible interactions. Toxicity can be increased
in the debilitated and older patient with symptoms not as
apparent.
ACTIONS/INTERVENTIONS
Medication Management (NIC)
Independent
Discuss self-administration of/access to OTC products.
Identify swallowing problems or reluctance to take tablets
or capsules.
Give pills in a spoonful of soft foods, e.g., applesauce, ice
cream; or use liquid form of medication if available.
Open capsules or crush tablets only when appropriate.
Make sure medication has been swallowed.
Observe for changes in condition/behavior.
Use discretion in the administration of sedatives.
Collaborative
Review drug regimen routinely with physician and
pharmacist.
Obtain serum drug levels as indicated.
RATIONALE
Limits interference with prescribed regimen/desired drug
action and organ function. May prevent inadvertent
overdosing/toxic reactions. Note: Appropriate use of OTC
products kept at bedside or via free access at nurses’
station fosters independence and enhances sense of
control and self-esteem.
May not be able to or want to take medication.
Ensures proper dosage if patient is unable to/does not like
to swallow pills.
Should not be done unless absolutely necessary because
this may alter absorption of medications; e.g., enteric-
coated tablets, when crushed, may be absorbed in
stomach instead of the intestines.
Ensures effective therapeutic use of medication and
prevents pill hoarding.
Behavior may be only indication of drug toxicity, and
early identification of problems provides for appropriate
intervention. Note: Elderly individuals have increased
sensitivity to anticholinergic effects of medications;
therefore, use of anticholinergics, antiparkinson agents,
benzodiazepines, CNS depressants, and tricyclic
antidepressants may cause delirium/confusion.
A quiet place where patient can pace, or seclusion, may
be more helpful. If patient is destructive or excessively
disruptive, pharmacological or mechanical control
measures may be required. Convenience of the staff is
never a reason for sedating patient; however, patient
safety and rights of other patients need to be taken into
consideration.
Provides opportunity to alter therapy (e.g., reduce dosage,
discontinue medications) as patient’s needs and organ
functions change.
Determines therapeutic/toxicity levels.
 NURSING DIAGNOSIS: Communication, impaired verbal
May be related to
Degenerative changes (e.g., reduced cerebral circulation, hearing loss);
progressive neurological disease (e.g., Parkinson’s disease, Alzheimer’s disease)
Laryngectomy/tracheostomy; stroke, traumatic brain injury
Possibly evidenced by
Impaired articulation; difficulty with phonation; inability to modulate speech, find words, name, or identify
objects (aphasia, dysarthria)
Diminished hearing ability
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Communication Ability (NOC)
Establish method of communication by which needs can be expressed.
Demonstrate congruent verbal and nonverbal communication.

ACTIONS/INTERVENTIONS RATIONALE
Communication Enhancement: Speech Deficit
(NIC)

Independent
Assess reason for lack of communication, including CNS
and neuromuscular functioning, gag/swallow reflexes,
hearing, teeth/mouth problems.
Identification of the problem is essential to appropriate
intervention. Sometimes patients do not want to talk, may
think they talk when they do not, may expect others to
know what they want, may not be able to comprehend or
be understood.

Determine whether patient is bilingual or whether English With declining cerebral function/diminished thought
is primary language. processes, increased level of stress, patient may mix
languages/revert to original language.

Investigate how SO communicates with patient. Provide opportunity to develop/continue effective

communication patterns, which have already been
established.

Assess patient knowledge base and level of Knowing how much to expect of patient can help to avoid
comprehension. Treat patient as an adult, avoiding pity frustration and unreasonable demands for performance.
and impatience. However, having an expectation that patient will
understand may help raise level of performance.

Establish therapeutic nurse-patient relationship through Aids in dealing with communication problems.
Active-Listening, being available for problem solving.

Make patient aware of presence when entering the room Getting attention is the first step in communication.
by speaking, turning a light off and on/touching patient or
mattress as appropriate.

Make eye contact, place self at or below patient’s level, Conveys interest and promotes contact.
and speak face to face.
ACTIONS/INTERVENTIONS RATIONALE
Communication Enhancement: Speech Deficit
(NIC)

Independent
Speak slowly and distinctly, using simple sentences, Assists in comprehension and overall communication.
yes/no questions. Avoid speaking loudly or shouting. Patient may respond poorly to high-pitched sounds;
Supplement with written communication when shouting also obscures consonants and amplifies vowels.
possible/needed. Allow sufficient time for reply; remain
relaxed with patient.

Use other creative measures to assist in communication, Many options are available, depending on individual
e.g., picture chart/alphabet board, sign language, lip situation. Note: Sign language also may be used
reading when appropriate. effectively with other than hearing-impaired individuals.

Communication Enhancement: Hearing Deficit

(NIC)

Check ears for excess cerumen. Hardened earwax may decrease hearing acuity and causes
tinnitus.

Ascertain whether patient has/uses hearing aid. Patient may have, but not use, hearing aid (e.g., may not
fit well, may need batteries).

Be aware that behavioral problems may be associated Anger, explosive temper outbursts, frustration,
with hearing loss. embarrassment, depression, withdrawal, and paranoia
may be attempts to deal with communication problems.

Collaborative

Refer to speech therapists; ear, nose, and throat physician;
or for audiometry as needed.
May be helpful to patient and staff in improving
communication. Determines extent of hearing loss and
whether a hearing aid is appropriate. Note: Some sources
believe 90% of patients in extended-care facilities have
some degree of hearing loss (presbycusis) because this is
a common age change. Hearing aids are most effective
with conductive losses and may help with sensorineural
losses.

NURSING DIAGNOSIS: Sleep Pattern, disturbed

May be related to
Internal factors: illness, psychological stress, inactivity
External factors: environmental changes, facility routines
Possibly evidenced by
Reports of difficulty in falling asleep/not feeling well-rested
Interrupted sleep, awakening earlier than desired
Change in behavior/performance, increasing irritability, listlessness
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Sleep (NOC)
Report improvement in sleep/rest pattern.
Verbalize increased sense of well-being and feeling rested.
ACTIONS/INTERVENTIONS
Sleep Enhancement (NIC)
Independent
Ascertain usual sleep habits and changes that are
occurring.
Provide comfortable bedding and some of own
possessions, e.g., pillow, afghan.
Establish new sleep routine incorporating old pattern and
new environment.
Match with roommate who has similar sleep patterns and
nocturnal needs.
Encourage some light physical activity during the day.
Make sure patient stops activity several hours before
bedtime as individually appropriate.
Promote bedtime comfort regimens, e.g., warm bath and
massage, a glass of warm milk, wine, or brandy at
bedtime.
Instruct in relaxation measures.
Reduce noise and light.
Encourage position of comfort, assist in turning as
needed.
Place bed in low position, against wall as indicated.
Avoid use of side rails. Place mat on floor if appropriate.
Avoid interruptions when possible (e.g., awakening for
medications or therapies).
Collaborative
Administer sedatives, hypnotics, as indicated.
RATIONALE
Determines need for action and helps identify appropriate
interventions.
Increases comfort for sleep and
physiological/psychological support.
When new routine contains as many aspects of old habits
as possible, stress and related anxiety may be reduced,
enhancing sleep.
Decreases likelihood that “night owl” roommate may
delay patient’s falling asleep or create interruptions that
cause awakening.
Daytime activity can help patient expand energy and be
ready for nighttime sleep; however, continuation of
activity close to bedtime may act as a stimulant, delaying
sleep.
Promotes a relaxing, soothing effect. Note: Milk has
soporific qualities, enhancing synthesis of serotonin, a
neurotransmitter that helps patient fall asleep faster and
sleep longer.
Helps induce sleep.
Provides atmosphere conducive to sleep.
Repositioning alters areas of pressure and promotes rest.
Presense of confusion/nighttime disorientation places
patient at risk for falls. Side rails pose a safety risk for
falls (as when trying to climb out of bed to void) or for
entrapment/death. Note: Small grab bar properly installed
may facilitate patient getting out of bed.
Uninterrupted sleep is more restful, and patient may be
unable to return to sleep when wakened.
May be given to help patient sleep/rest during transition
period from home to new setting. Note: Avoid habitual
use, because these drugs decrease REM (rapid eye
movement) sleep time.
 NURSING DIAGNOSIS: Nutrition: imbalanced, less/more than body requirements
May be related to
Impaired dentition; dulling of senses of smell and taste
Cognitive limitations, depression
Inability to feed self effectively
Sedentary activity level
Possibly evidenced by
Reported/observed dysfunctional eating patterns
Weight under/over ideal for height and frame
Poor muscle tone, pale conjunctivae/mucous membranes
Signs/symptoms of vitamin/protein deficits, electrolyte imbalances
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Nutritional Status (NOC)
Maintain normal weight or progress toward weight goal with normalization of laboratory values and be free of
signs of malnutrition/obesity.
Demonstrate eating patterns/behaviors to maintain appropriate weight.

ACTIONS/INTERVENTIONS RATIONALE
Nutrition Management (NIC)

Independent
Assess causes of weight loss/gain, e.g., dysphagia due to
decreased saliva production, neurogenic/psychogenic
disturbances, tumors, muscular dysfunction, altered
senses of smell and taste, or dysfunctional eating patterns
related to depression.
Aids in creating plan of care/choice of interventions.
Note: In elderly patients, saliva secretion may be
decreased by as much as 66%, taste buds atrophy with
reduced sensitivity to sweet and salt.

Check state of patient’s dental health periodically, Oral infections/dental problems, shrinking gums, and
including fit and condition of dentures, if present. loose-fitting dentures decrease patient’s ability to chew.

Weigh on admission and on a regular basis. Monitors nutritional state and effectiveness of
interventions.

Monitor total caloric intake as indicated. If dietary plan is ineffective in meeting individual goals,
calorie count/food diary may help identify problem areas.

Observe condition of skin; note muscle wasting, brittle Reflects lack of adequate nutrition.
nails; dry, lifeless hair, and signs of poor healing.

Evaluate activity pattern. Extremes of exercise (e.g., sedentary life, continuous

pacing) affect caloric needs.

Incorporate favorite foods and maintain as near-normal Aids in maintaining intake, especially when mouth and
food consistency as possible, e.g., soft or finely ground dental problems exist. Baby food is often unpalatable and
food with gravy or liquid added. Avoid baby food can decrease appetite and lower self-esteem.
whenever possible.

ACTIONS/INTERVENTIONS RATIONALE
Nutrition Management (NIC)
Independent
Encourage the use of spices (other than sodium) to
patient’s personal taste.
Provide small, frequent feedings as indicated.
Serve hot foods hot and cold foods cold.
Promote a pleasant environment for eating, with company
if possible.
Have healthy snack foods (e.g., cheese, crackers, soup,
fruit) available on a 24-hr basis.
Plan for social events; provide for snacks, even when
working to reduce total calories.
Encourage exercise and activity program within
individual ability.
Collaborative
Consult with dietitian.
Provide balanced diet with individually appropriate
protein, complex carbohydrates, and calories. Include
supplements between meals as indicated.
Administer vitamin/mineral supplements as appropriate.
Refer for dental care routinely and as needed.
Reduction in number and acuity of taste buds results in
food tasting bland and decreases enjoyment of food and
desire to eat.
Decreased gastric motility causes patient to feel full and
reduces intake.
Foods served at the proper temperature are more
palatable, and enjoyment may increase appetite.
Eating is in part a social event, and appetite can improve
with increased socialization.
Helps meet individual needs and enhances intake within
caloric recommendations.
Eating is part of socialization, and being able to respond
to body’s needs enhances sense of control and willingness
to participate in dietary program.
Promotes sense of well-being and may improve appetite.
Aids in establishing specific nutritional program to meet
individual patient needs.
Adjustments may be needed to deal with the body’s
decreased ability to process protein, as well as decreased
metabolic rate and levels of activity. Note: Reduced
production of salivary ptyalin inhibits digestion of
complex carbohydrates in elderly individuals, affecting
dietary plan. In addition, delayed insulin release by the
pancreas and reduced peripheral sensitivity to insulin can
decrease glucose tolerance.
With age, renal and other regulatory systems cannot
compensate as well for errors in intake. Mineral
requirements change as hormone levels, metabolism, and
GI function change. In addition, absorption can be
impaired by medication use and chronic illness.
Maintenance of oral/dental health and good dentition can
enhance intake.
 NURSING DIAGNOSIS: Self-Care deficit: (specify)
May be related to
Depression, discouragement, loss of mobility, general debilitation; perceptual/cognitive impairment
Possibly evidenced by
Inability to manage ADLs; unkempt appearance
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Self-Care: Activities of Daily Living (ADL) (NOC)
Peform self-care activities within level of own ability.
Demonstrate techniques/lifestyle changes to meet own needs.
Use resources effectively.

ACTIONS/INTERVENTIONS RATIONALE
Self-Care Assistance (NIC)

Independent
Determine current capabilities (0–4 scale) and barriers to Identifies need for/level of interventions required.
participation in care.

Involve patient in formulation of plan of care at level of Enhances sense of control and aids in cooperation and
ability. maintenance of independence.

Encourage self-care. Work with present abilities; do not Doing for oneself enhances feeling of self-worth. Failure
pressure patient beyond capabilities. Provide adequate can produce discouragement and depression.
time for patient to complete tasks. Have expectation of
improvement and assist as needed.

Provide and promote privacy, including during bathing/ Modesty may lead to reluctance to participate in care or
showering. perform activities in the presence of others.

Use specialized equipment as needed, e.g., tub transfer Enhances ability to move/perform activities safely.
seat, grab bars, raised toilet seat.

Give tub bath, using a two-person or mechanical lift if Provides safety for those who cannot get into the tub
necessary. Use shower chair and spray attachment, as alone. Shower may be more feasible for some patients,
appropriate. Avoid chilling. although it may be less beneficial/desirable to patient.
Elderly/debilitated patients are more prone to chilling.

Shampoo/style hair as needed. Provide/assist with Aids in maintaining appearance. Shampooing may be
manicure. required more/less frequently than bathing schedule.

Encourage use of barber/beauty salon if patient is able. Enhances self-image and self-esteem, preserving dignity
of patient.

Acquire clothing with modified fasteners as indicated. Use of Velcro instead of buttons/shoelaces can facilitate
process of dressing/undressing.

Encourage/assist with routine mouth/teeth care daily. Reduces risk of gum disease/tooth loss; promotes proper
fitting of dentures.
ACTIONS/INTERVENTIONS RATIONALE
Self-Care Assistance (NIC)

Collaborative
Consult with physical/occupational therapists and Useful in establishing exercise/activity program and in
rehabilitation specialist. identifying assistive devices to meet individual
needs/facilitate independence.

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include
General debilitation; reduced mobility; changes in skin and muscle mass associated with aging, sensory/motor
deficits
Altered circulation; edema; poor nutrition
Excretions/secretions (bladder and bowel incontinence)
Problems with self-care
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Risk Control (NOC)
Maintain intact skin.
Identify individual risk factors.
Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing.

ACTIONS/INTERVENTIONS RATIONALE
Skin Surveillance (NIC)

Independent
Inspect skin, tissues, and mucous membranes routinely. Provides opportunity for early intervention in potential
high-risk population, who may have thin, less elastic, and
more fragile skin and tissues.

Anticipate and use preventive measures in patients who Decubitus ulcers are difficult to heal, and prevention is
are at risk for skin breakdown, such as anyone who is the best treatment.
thin, obese, aging, or debilitated.

Assess nutritional status and initiate corrective measures A positive nitrogen balance and improved nutritional state
as indicated. Provide balanced diet, e.g., adequate protein, can help prevent skin breakdown and promote ulcer
vitamins, and minerals. healing. Note: May need additional calories and protein if
draining ulcer present.

Maintain strict skin hygiene, using mild, nondetergent
soap (if any), drying gently and thoroughly, and
lubricating with lotion or emollient.
A daily bath is usually not necessary in elderly patients
because there is atrophy of sebaceous and sweat glands,
and bathing may create dry-skin problems. However, as
epidermis thins with age, cleansing and use of lubricants
is needed to keep skin soft/pliable and protect susceptible
skin from breakdown.
ACTIONS/INTERVENTIONS
Skin Surveillance (NIC)
Independent
Change position frequently in bed and chair. Recommend
10 min of exercise each hr and/or perform passive ROM.
Use a rotation schedule in turning patient. Use draw/turn
sheet. Pay close attention to patient’s comfort level.
Massage bony prominences gently with lotion or cream.
Keep sheets and bedclothes clean, dry, and free from
wrinkles, crumbs, and other irritating material.
Use elbow/heel protectors, foam/water or gel pads,
sheepskin for positioning in bed and when up in chair.
Provide for safety during ambulation, using appropriate
adaptive devices, e.g., walker, cane.
Limit exposure to temperature extremes/use of heating
pad or ice pack.
Examine feet and nails routinely and provide foot and nail
care as indicated:
Keep nails cut short and smooth;
Use lotion, softening cream on feet;
Check for fissures between toes, swab with hydrogen
peroxide or dust with antiseptic powder, and place a wisp
of cotton between the toes;
Rub feet with witch hazel or a mentholated preparation
and have patient wear lightweight cotton stockings.
Inspect skin surface/folds (especially when incontinence
pad/pants are used) and bony prominences routinely.
Increase preventive measures when reddened areas are
noticed.
RATIONALE
Improves circulation, muscle tone, and joint motion and
promotes patient participation.
Allows for longer periods free of pressure; prevents
shearing or tearing motions that can damage fragile
tissues. Note: Use of prone position depends on patient
tolerance and should be maintained for only a short time.
Enhances circulation to tissues, increases vascular tone,
and reduces tissue edema. Note: Contraindicated if area is
pink/red because cellular damage may occur. Gentle
massage around area may stimulate circulation to
impaired tissues.
Avoids friction/abrasions of skin.
Reduces risk of tissue abrasions and decreases pressure
that can impair cellular blood flow. Promotes circulation
of air along skin surface to dissipate heat/moisture.
Loss of muscle strength and flexibility and physical
disease process/debilitation may result in impaired
coordination.
Decreased sensitivity to pain/heat/cold increases risk of
tissue trauma.
Foot problems are common among patients who are
elderly, diabetic, bedfast, and/or debilitated.
Jagged, rough nails can cause tissue damage/infection.
Prevents drying/cracking of skin; promotes maintenance
of healthy skin.
Prevents spread of infection and/or tissue injury.
Even though rash may not be present, burning and itching
may be a problem. Note: Witch hazel may be
contraindicated if skin is dry.
Skin breakdown can occur quickly with potential for
infection and necrosis, possibly involving muscle and
bone. There is increased risk of redness/irritation around
legs as a result of elastic bands in adult
diapers/incontinence pads.
ACTIONS/INTERVENTIONS RATIONALE
Skin Surveillance (NIC)

Independent
Continue regimen for redness and irritation when break in Aggressive measures are important because decubitus
skin occurs. ulcers can develop in a matter of a few hours.

Collaborative

Observe for decubitus ulcer development, and treat Timely intervention may prevent extensive damage.
immediately according to protocol.

Provide waterbed, alternating pressure/egg-crate or gel Provides protection and improved circulation by
mattress, and pad for chair. decreasing amount of pressure on tissues.

Monitor Hb/Hct and blood glucose levels. Anemia, dehydration, and elevated glucose levels are
factors in skin breakdown and can impair healing.

Refer to podiatrist as indicated. May need professional care for such problems as ingrown
toenails, corns, bony changes, skin/tissue ulceration.

Provide whirlpool treatments as appropriate. Increases circulation and has a debriding action.

Assist with topical applications; hydrogel dressings; skin Although there are differing opinions about the efficacy
barrier dressings (DuoDerm, Opsite); collagenase of these agents, individual or combination use may
therapy; absorbable gelatin sponges (Gelfoam); aerosol enhance healing.
sprays.
Aids in healing/cellular regeneration.
Administer nutritional supplements and vitamins as
indicated.
May be needed to close large ulcers.
Prepare for/assist with skin grafting. (Refer to CP: Burns,
ND: Skin Integrity, impaired.)

NURSING DIAGNOSIS: Urinary Elimination, risk for impaired

Rick factors may include
Changes in fluid/nutritional pattern
Neuromuscular changes
Perceptual/cognitive impairment
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Urinary Elimination (NOC)
Maintain/regain effective pattern of elimination.
Initiate necessary lifestyle changes.
Participate in treatment regimen to correct/control situation, e.g., bladder training program or use of indwelling
catheter.
ACTIONS/INTERVENTIONS
Urinary Elimination Management (NIC)
Independent
Monitor voiding pattern. Identify possible reasons for
changes, e.g., disorientation, neuromuscular impairment,
psychotropic medications.
Palpate bladder. Observe for “overflow” voiding;
determine frequency and timing of dribbling/voiding.
Promote fluid intake of 2000–3000 mL/day within
cardiac tolerance; include fruit juices, especially
cranberry juice. Schedule fluid intake times appropriately.
Institute bladder program (including scheduled voiding
times, Kegel exercise) involving patient and staff in a
positive manner.
Assist patient to sit upright on bedpan/commode.
Provide/encourage perineal care daily and as needed.
Use adult incontinence pads/pants during day if needed.
Keep patient clean and dry. Provide frequent skin care.
Avoid verbal or nonverbal signs of rejection, disgust, or
disapproval over failures.
Provide regular catheter care and maintain patency if
indwelling catheter is present.
Collaborative
Administer medications as indicated, e.g.:
Oxybutynin chloride (Ditropan); tolterodine
tartrate(Detrol);
Vitamin C, methenamine mandelate (Mandelamine).
Maintain indwelling catheter/provide intermittent
catheterization.
Irrigate catheter with acetic acid solution, if indicated.
RATIONALE
This information is essential to plan for care and
influences choice of individual interventions. Nocturia,
frequency, and urgency are common because bladder
capacity and/or tone is affected. Bladder pelvic muscles
and sphincter tone may be affected.
Bladder distension indicates urinary retention, which may
cause incontinence and infection.
Maintains adequate hydration and promotes kidney
function. Acid-ash juices act as an internal pH acidifier,
retarding bacterial growth. Note: Patient may decrease
fluid intake in an attempt to control incontinence and
become dehydrated. Instead, fluids may be scheduled to
decrease frequency of incontinence (e.g., limit fluids after
6 PM to reduce need to void during the night).
Regular toileting times may help control incontinence.
Program is more apt to be successful when positive
attitudes and cooperation are present.
Provides functional position for voiding.
Reduces risk of contamination/ascending infection.
When training is unsuccessful, this is the preferred
method of management. Note: Using incontinence pads
during night allows exposure of skin to air, reducing risk
of irritation.
Expressions of disapproval lower self-esteem and are not
helpful to a successful program.
Prevents infection and/or minimizes reflux.
Promotes bladder sphincter control.
Bladder pH acidifiers retard bacterial growth.
May be used if continence cannot be maintained to
prevent skin breakdown and resultant problems.
May be done to maintain acid pH and retard bacterial
growth.
 NURSING DIAGNOSIS: Constipation/Diarrhea, risk for
Risk factors may include
Changes in/inadequate nutrition or fluid intake; poor muscle tone, change in level of activity
Medication side effects
Perceptual/cognitive impairment, depression
Lack of privacy
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Bowel Elimination (NOC)
Establish/maintain normal patterns of bowel functioning.
Demonstrate changes in lifestyle as necessitated by risk or contributing factors.
Participate in bowel program, as indicated.

ACTIONS/INTERVENTIONS RATIONALE
Bowel Management (NIC)

Independent
Ascertain usual bowel pattern and aids used (e.g., Determines extent of problem and indicates need for/type
previous long-term laxative use). Compare with current of interventions appropriate. Many patients may already
routine. be laxative-dependent, and it is important to reestablish as
near-normal functioning as possible.

Assess reasons for problems; rule out medical causes, Identification/treatment of underlying medical condition
e.g., bowel obstruction, cancer, hemorrhoids, drugs, is necessary to achieve optimal bowel function.
impaction.

Determine presence of food/drug sensitivities. May contribute to diarrhea.

Institute individualized program of exercise, rest, diet, Depends on the needs of patient. Loss of muscular tone
and bowel retraining. reduces peristalsis or may impair control of rectal
sphincter.

Provide diet high in bulk in the form of whole-grain Improves stool consistency, promotes evacuation.
cereals, breads, fresh fruits (especially prunes, plums).

Decrease or eliminate foods such as dairy products. These foods are known to be constipating.

Encourage increased fluid intake. Promotes normal stool consistency.

Use adult incontinence pads/pants, if needed. Keep Prevents skin breakdown.

patient clean and dry. Provide frequent perineal care.
Apply skin protective ointment to anal area.

Keep air freshener in room/at bedside or in bathroom. Limits noxious odors and may help reduce patient
embarrassment/concern.

ACTIONS/INTERVENTIONS RATIONALE
Bowel Management (NIC)

Independent
Give emotional support to patient. Avoid “blaming” Decreases feelings of frustration and embarrassment.
(talk/actions) if incontinence occurs.

Collaborative

Administer medications as indicated:

Bulk-providers/stool softeners, e.g., Metamucil; Promotes regularity by increasing bulk and/or improving
stool consistency.

Camphorated tincture of opium (Paregoric), May be needed on a short-term basis when diarrhea
diphenoxylate with atropine (Lomotil). persists.

NURSING DIAGNOSIS: Falls, risk for

Risk factors may include
Presence of arthritis, decreased ROM, difficulty with mobility
Use of assistive devices (e.g., walker, cane)/wheelchair
Perceptual/cognitive impairments
Problems with continence
Medication use (e.g., antihypertensives, angiotensin-converting enzyme [ACE] inhibitors, diuretics)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Safety Behavior: Fall Prevention (NOC)
Verbalize understanding of indvidual factors that contribute to possibility of injury.
Demonstrate techniques/behaviors to enhance safety and reduce individual risks.
Be free of falls/associated injury.

ACTIONS/INTERVENTIONS RATIONALE
Fall Prevention (NIC)

Independent
Determine functional ability (0–4 Functional Level scale), Identifies need for/degree of intervention required.
nature of any impairment (physical, cognitive), and
perform fall risk screen.

Plan activities/visits with adequate rest periods as Prevents fatigue.

necessary.

Supervise participation in/assist with self-care, Promotes independence and self-esteem, while meeting
occupational/recreational activities as appropriate. safety needs.
Encourage patient to call for assistance as needed.

ACTIONS/INTERVENTIONS
RATIONALE
Fall Prevention (NIC)
Independent

Provide chairs with firm, high seats and lifting Facilitates rising from seated position.
mechanisms when indicated.

Assist with transfers and ambulation if indicated; show Prevents accidental falls/injury, especially in patient with
patient/SO ways to move safely. altered gait, generalized weakness, orthostatic
hypotension, fatigue, and vision disturbances.

Obtain supportive shoes and well-fitting, nonskid Assists patient to walk with a firm step/maintain sense of
slippers. balance, and prevents slipping.

Remove extraneous furniture/scatter rugs from pathways. Prevents patient from bumping into furniture and reduces
Avoid clutter on floors. risk of falling/injuring self.

Encourage use of hand rails in hallway, stairwells, and Promotes independence in mobility; reduces risk of falls.
bathrooms. Keep bed height in low position.

Review safe use of mobility aids/adjunctive devices, e.g., Facilitates activity, reduces risk of injury.
walker, braces, prosthetics.

Provide for environmental changes to meet visual Prevents accidents and reduces sense of sensory
deficiencies. deprivation. If patient is visually impaired, will need
assistance and ongoing orientation to surroundings.

Speak to patient when entering the room, and let patient Special actions help patient who cannot see to know when
know when leaving. someone is there.

Encourage patient with eyeglasses/contact lenses to wear Optimal visual acuity facilitates participation in activities
them. Be sure eyeglasses are kept clean. Determine and reduces risk of falls/injury. Patient may not be
reason if eyeglasses are not being worn. wearing eyeglasses because they need adjustment or
change in correction.

Collaborative

Arrange for regular eye examinations. Identifies development/progression of vision problem

(e.g., myopia, hyperopia, presbyopia, astigmatism,
cataract and glaucoma, tunnel vision, loss of peripheral
fields, blindness) and specific options for care.

Consult with physical/occupational therapists, Useful in creating individual exercise/activity program

rehabilitation specialist. and identifying adjunctive aids. Note: Even in the elderly
population, inclusion of moderate weight-lifting in the
exercise program can improve bone density and help
maintain muscle tone/strength.
 NURSING DIAGNOSIS: Diversional Activity, deficient
May be related to
Environmental lack of diversional activity; long-term care requirements
Physical limitations; psychological condition, e.g., depression
Possibly evidenced by
Statements of boredom, depression, lack of energy
Disinterest, lethargy, withdrawn behavior, hostility
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Leisure Participation (NOC)
Recognize own response and initiate appropriate coping actions.
Engage in satisfying activities within personal limitations.

ACTIONS/INTERVENTIONS RATIONALE
Activity Therapy (NIC)

Independent
Determine avocation/hobbies patient previously pursued. Encourages involvement and helps stimulate patient
Incorporate activities, if appropriate, into present mentally/physically to improve overall condition and
program. sense of well-being.

Encourage participation in mix of activities/stimuli, e.g.,
music, news program, educational presentations, crafts,
social interactions, as appropriate.
Offering different activities helps patient try out new
ideas and develop new interests. Activities need to be
personally meaningful for patient to derive the most
enjoyment from them (e.g., talking or Braille books for
the blind, closed-caption TV broadcasts for the
deaf/hearing impaired).

Provide change of scenery when possible; alter personal Stimulates energy and provides new outlook for patient.
environment; encourage trips to shop/participate in
local/family events.

Collaborative

Refer to occupational therapist, activity director. Can introduce and design new programs to provide
positive stimuli for patient.
 NURSING DIAGNOSIS: Sexuality Patterns, risk for ineffective
Risk factors may include
Biopsychosocial alteration of sexuality
Interference in psychological/physical well-being; self-image
Lack of privacy/SO
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Sexual Functioning (NOC)
Verbalize knowledge and understanding of sexual limitations, difficulties, or changes that have occurred.
Demonstrate improved communication and relationship skills.
Identify appropriate options to meet needs.

ACTIONS/INTERVENTIONS RATIONALE
Sexual Counseling (NIC)

Independent
Note patient/SO cues regarding sexuality. May be concerned that condition/environmental
restrictions may interfere with sexual function or ability,
but is afraid to ask directly.

Determine cultural and religious/value factors and Affects patient’s perception of existing problems and
conflicts that may be present. response of others (e.g., family, staff, other residents).
Provides starting point for discussion and problem
solving.

Assess developmental and lifestyle issues. Factors such as menopause and aging, adolescence, and
young adulthood need to be taken into consideration with
regard to sexual concerns about illness and long-term
care.

Provide atmosphere in which discussion of sexuality is When concerns are identified and discussed, problem
encouraged/permitted. solving can occur.

Provide privacy for patient/SO. Demonstrates acceptance of need for intimacy, and
provides opportunity to continue previous patterns of
interaction as much as possible.

Collaborative
May require additional assistance for resolution of
Refer to sex counselor/therapist, family therapy when problems.
needed.
 NURSING DIAGNOSIS: Health Maintenance, impaired
May be related to
Lack of, or significant alteration in, communication skills
Complete or partial lack of gross and/or fine motor skills
Perceptual/cognitive impairment, lack of ability to make deliberate/thoughtful judgments
Lack of material resources
Possibly evidenced by
Demonstrated lack of knowledge regarding basic health practices
Reported/observed inability to take responsibility for meeting basic health needs; impairment of personal
support system
Demonstrated lack of behaviors adaptive to internal or external environmental changes
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT/CAREGIVER WILL:
Participation: Health Care Decisions (NOC)
Verbalize understanding of factors contributing to current situation.
Adopt lifestyle changes supporting individual healthcare goals.
Assume responsibility for own healthcare needs when possible.

ACTIONS/INTERVENTIONS RATIONALE
Health Education (NIC)

Independent
Assess level of adaptive behavior; knowledge and skills Identifies areas of concern/need and aids in choice of
about health maintenance, environment, and safety. interventions.

Provide information about individual healthcare needs. Provides knowledge base and encourages participation in
decision making.

Develop plan with patient/SO for self-care incorporating Assists patient/caregiver to maintain and manage desired
existing disabilities adapting and organizing care. level of independence when possible.

Maintain adequate hydration and balanced diet with Promotes general well-being and aids in disease
sufficient protein intake. prevention.

Schedule adequate rest with progressive activity program. Prevents fatigue and enhances general well-being.

Promote good handwashing and personal hygiene. Use Prevents contamination/cross-contamination, reducing
aseptic techniques as necessary. risk of illness/infection.

Protect from exposure to infections; avoid extremes of
temperature. Recommend the wearing of masks/other
interventions as indicated.
With age, immune protective responses slow down and
physiological reactions to temperature extremes may be
impaired. As organ function decreases (especially thymus
gland) and natural antibodies decline, patients are at
increased risk for infection. Staff and/or visitors with
colds or other infections may expose patient to these
illnesses.

Encourage cessation of smoking. Smokers are prone to bronchitis and ineffective clearing
of secretions.

Encourage reporting of signs/symptoms as they occur. Provides opportunity for early recognition of developing
complications and timely intervention to prevent serious
illness.
ACTIONS/INTERVENTIONS RATIONALE
Health System Guidance (NIC)

Independent
Note patient’s previous use of professional services, and Preserves continuity and promotes independence in
continue as appropriate. Include in choice of new meeting own healthcare needs.
healthcare providers as able.

Observe for/monitor changes in vital signs, e.g.,
temperature elevation.
Early identification of onset of illness allows for timely
intervention and may prevent serious complications.
Note: Elderly persons often display subnormal
temperatures, so presence of a low-grade fever may be of
serious concern.

Collaborative

Identify resources for/administer medications as

indicated:
Immunizations, e.g., Haemophilus influenzae (flu), Reduces risk of acquiring contagious/potentially life-
pneumonia; threatening diseases.

Antibiotics. May be used prophylactically, depending on individual

disease process/risk factors and to treat infections.

Schedule preventive/routine healthcare appointments Promotes optimal recovery/maintenance of health.

based on individual needs, e.g., with cardiologist,
podiatrist, ophthalmologist, dentist.

Refer to support services as indicated, e.g., home health Many community resources are available, and often
agency, durable medical equipment company, Senior untapped, to make life and care of the individual easier.
Resources, social services, national hospice organization,
Alzheimer’s Disease and Related Disorders Association,
American Association of Retired Persons [AARP], Center
for Health Care Ethics, Choice in Dying, American Bar
Association, Commission on Legal Problems of the
Elderly, Adult Protective Services; Internet resources

POTENTIAL CONSIDERATIONS following discharge from care facility

Refer to plan of care for diagnosis that required admission.