Nursing Diagnosis – Code 00257 Frail elderly syndrome (2013; LOE 2.1)

Domain 1. Health Promotion Class 2. Health Management

Frail elderly syndrome

Definition Dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domain of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.

Defining Characteristics

■ Activity intolerance (00092) ■ Bathing self-care deficit (00108) ■ Decreased cardiac output (00029) ■ Dressing self-care deficit (00109) ■ Fatigue (00093) ■ Feeding self-care deficit (00102)
■ Hopelessness (00124) ■ Imbalanced nutrition: less than body requirements (00002) ■ Impaired memory (00131) ■ Impaired physical mobility (00085) ■ Impaired walking (00088) ■ Social isolation (00053) ■ Toileting self-care deficit (00110)

Related Factors

■ Alteration in cognitive functioning ■ Chronic illness ■ History of falls ■ Living alone ■ Malnutrition
■ Prolonged hospitalization ■ Psychiatric disorder ■ Sarcopenia ■ Sarcopenic obesity ■ Sedentary lifestyle

Nursing Diagnosis – Code 00168 Sedentary lifestyle (2004; LOE 2.1)

Domain 1. Health Promotion Class 1. Health Awareness

Sedentary lifestyle

Definition Reports a habit of life that is characterized by a low physical activity level.

Defining Characteristics

■ Average daily physical activity is less than recommended for gender and age
■ Physical deconditioning ■ Preference for activity low in physical activity

Related Factors

■ Insufficient interest in physical activity ■ Insufficient knowledge of health benefits associated with physical exercise
■ Insufficient motivation for physical activity ■ Insufficient resources for physical activity ■ Insufficient training for physical exercise


Nursing Diagnosis – Code 00097 Deficient diversional activity (1980)

Domain 1. Health Promotion Class 1. Health Awareness

Deficient diversional activity

Definition Decreased stimulation from (or interest or engagement in) recreational or leisure activities.

Defining Characteristics

■ Boredom ■ Current setting does not allow engagement in activity

Related Factors

■ Insufficient diversional activity ■ Extremes of age
■ Prolonged hospitalization ■ Prolonged institutionalization

Nursing diagnosis – NONCOMPLIANCE



Behavior of person and/or caregiver that fails to coincide with a

health-promoting or therapeutic plan agreed on by the person

(and/or family and/or community) and health-care professional. In

the presence of an agreed-on, health-promoting or therapeutic plan,

person’s or caregiver’s behavior is fully or partially nonadherent and

may lead to clinically ineffective or partially ineffective outcomes


• Behavior indicative of failure to progress

• Complications or evidence of exacerbation of signs and symptoms

• Failure to keep appointments and adhere to treatment regimen

• Objective indications (e.g., laboratory tests, physiologic markers)


Health system


• Access to, convenience of care

• Cultural/spiritual values

• Client–provider relationships

• Developmental and personal

• Individual health coverage


• Provider communication skills,

• Health beliefs

credibility; continuity; teaching
skills; reimbursement

• Knowledge of regimen
• Motivational forces

Healthcare plan


• Complexity, intensity

• Involvement of members in

• Cost, financial flexibility, and

health plan

duration of plan

• Social value regarding plan

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Beliefs/values

• Roles/responsibilities

• Coping

• Self-perception

• Emotional status


The patient will

• Identify factors that influence noncompliance.

• Demonstrate level of compliance that maintains safety.

• Contract to perform specific behaviors.

• Use support systems to modify noncompliant behaviors.


Acceptance: Health Status; Adherence Behavior; Compliance Behav-

ior; Symptom control; Treatment Behavior


Determine:  Assess patient’s perception of health problem, treatment

regimen and history of compliance, obstacles to compliance, financial


resources, ethnicity, and religious influences. Assessment information

may help select appropriate interventions.

Perform:  Provide an environment that is nonjudgmental. This

demonstrates unconditional respect for the patient.

Contract with the patient to practice only nonthreatening behav-

iors. This involves the patient in a formal commitment and gives the

patient a sense of personal control.

Inform:  Teach self-healing techniques to both the patient and family

such as meditation, guided imagery, yoga, and prayer. These

techniques promote self-reliance.

Teach principles of good nutrition for patient’s specific condition.

Understanding importance of nutrition will encourage compliance.

Inform patient about diagnosis. Understanding essential informa-

tion needed to perform skills or give self-care increases compliance.

Demonstrate skills needed by patient to comply with treatment regi-

men to reinforce patient’s confidence in ability to replicate.

Attend:  Provide opportunities for the patient to discuss reasons for

noncompliance. The willingness of the nurse to listen allows the

patient the ability to listen to his or her own reasoning.

Help patient clarify his or her values about the importance of fol-

lowing a treatment plan to determine appropriate interventions.

Acknowledge patient’s right to choose not to comply with

prescribed regimen to respect autonomy. Control over patient’s

actions is legitimate only when dangerous to self or others. Offer

positive reinforcement.

Use support systems to reinforce negotiated behaviors. Support

from the family and friends help foster compliance.

Manage: When medically appropriate, support patient’s cultural

beliefs towards medical practices to demonstrate respect; and refer

to a member of the clergy or a spiritual counselor.

Refer family to community resources and support groups to pro-

mote compliance with modification of behavior. If patient’s situation

is complicated by lack of financial resources, contact agencies that

may offer help with costs of medical treatment.


Coping Enhancement; Counseling; Decision-Making Support; Health

Education; Patient Contracting; Self-Modification Assistance; Self-

Responsibility Facilitation


Riegel, B., et al. (2006, May–June). A motivational counseling approach to

improving heart failure self-care mechanisms of effectiveness. Journal of
Cardiovascular Nursing, 21(3), 232–241.

Nursing diagnosis – UNILATERAL NEGLECT



Impairment in sensory and motor response, mental representation,

and spatial attention of the body and the corresponding environ-

ment characterized by inattention to one side and overattention to

the opposite side. Left side neglect is more severe and persistent

than right side neglect


• Consistent inattention to stimuli/positioning on affected side

• Failure to eat food on plate on the affected side

• Inadequate self-care

• Failure to move eyes, head, limbs, or trunk in the affected hemi-

space despite awareness of stimulus in that space

• Marked deviation of the eyes, head, or trunk to the nonaffected

side by stimuli and activities on that side (as if drawn by Magnet)

• Perseveration of visual motor tasks on the nonaffected side


• Brain injury from tumor, or cerebrovascular, neurological, or trau-

matic causes

• Left hemiplegia from CVA of right hemisphere

• Hemianopsia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Self-care

• Coping

• Sensation/perception

• Neurocognition

• Tissue integrity


The patient/family will

• Avoid injury, skin breakdown and contractures on affected body part.

• Recognize the neglected body part.

• Demonstrate exercises for the affected body part.

• Demonstrate measures for maximum functioning and arrange

environment to protect the affected body part.

• Express feelings about altered state of health and neurologic deficits.

• Identify community resources and support groups to help cope

with the effects of illness.


Adaptation to Physical Disability; Body Image; Body Mechanics Per-

formance; Body Positioning: Self-Initiated; Self-Care: ADLs


Determine:  Observe the position of the affected body part frequently

to prevent injury.

Perform:  Place a sling on the affected arm to prevent dangling or injury.

Support affected leg and foot and perform other measures, as

appropriate, to keep patient’s limbs in functional position and avoid


contractures. Use a drawsheet to move patient up in bed to avoid

skin abrasions.

Touch and rub the affected limb, and describe the limb in conversa-

tion with patient. This reminds the patient of the neglected body part.

Use safety belts or protective devices to remind patient of limita-

tions and prevent falls. Use devices according to facility policy.

Remove splints and other devices at least every 2 hr. Inspect the

skin for pressure areas. Reapply the splint. Proper use of splints and

other devices prevents deformities and maintains skin integrity.

Perform ROM exercises on the affected side at least once every

shift, unless medically contraindicated, to maintain joint flexibility

and prevent contractures. Establish and follow a regular turning

schedule to maintain skin integrity.

Arrange environment for maximum functioning; for example,

place water, television controls, and the call bell within reach. These

measures enhance orientation and encourage independence.

Assist patient with ADLs or provide supervision, as appropriate,

to protect patient’s affected side.

Inform:  Encourage patient to perform activities that require use of

the affected limb to more easily integrate paretic or paralyzed limb

into body image.

Instruct family and nursing personnel to observe the position of

the affected body part frequently; to remove food or drainage from

the face if unnoticed by patient; and to place the arm or leg in the

proper position as often as necessary. These measures help avoid

injury and maintain dignity.

Attend:  Encourage patient to check the position of the affected body

part with each repositioning or transfer to reestablish awareness of

the body part.

Encourage patient and family members to express their feelings

regarding patient’s condition and level of functioning to release ten-

sion and enhance coping.

Manage:  Request consultations with occupational and physical ther-

apists about adaptive equipment and exercise programs to promote

use of the affected limb.

Refer patient and family members to appropriate support groups

and other community resources to assist in adjusting to patient’s

altered state of health.


Body Image Enhancement; Exercise Therapy: Joint Mobility; Mutual

Goal-Setting; Self-Care Assistance; Unilateral Neglect Management


Macko, R. F., et al. (2005, Winter). Task-oriented aerobic exercise in chronic

hemiparetic stroke: Training protocols and treatment effects. Topics in
Stroke Rehabilitation, 12(1), 45–57.

Nursing diagnosis – NAUSEA



A subjective unpleasant, wavelike sensation in the back of the throat,

epigastrium, or abdomen that may lead to the urge or need to vomit


• Gagging sensation

• Gastric stasis

• Increased salivation, swallowing

• Sour taste in the mouth

• Uninterested in eating; does not have appetite

• Reports “nausea” or “sick to the stomach”




• Biochemical disorders

• Anxiety

• Esophageal disease

• Fear

• Gastric distention, irritation

• Noxious odors, taste, visual

• Increased intracranial pressure


• Motion sickness

• Pain

• Pain

• Physiological factors

• Pancreatic disease


• Tumors, intra-abdominal or

• Gastric distention, irritation

localized tumors

• Pharmaceuticals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Knowledge

• Fluid and electrolytes

• Comfort

• Pharmacological function


The patient will

• State reasons for nausea and vomiting.

• Take steps to manage episodes of nausea and vomiting.

• Ingest sufficient nutrients to maintain health.

• Take steps to ensure adequate nutrition when nausea abates.

• Maintain weight within specified limits.


Appetite; Comfort Level; Fluid Balance; Hydration; Nausea & Vom-

iting Control; Nutritional Status: Food & Fluid Intake; Suffering

Severity; Symptom Control


Determine:  Assess for illness, pregnancy, medication use (prescription

and over-the-counter); exposure to tainted foods, chemicals, occupational

hazards; weight (fluctuation in last 6 months); food preferences and usual

dietary patterns; history of gastric/esophageal problems. Assessment infor-

mation will help in identifying appropriate interventions.

Monitor direct observation of food and fluid intake to ensure

whether or not the patient is receiving adequate nutritional intake.

Perform:  Provide comfort measures (e.g., back massage, warm bath)

to promote feelings of comfort for the patient.

Reduce noise, control odors, and adjust light in the environment

to help the patient relax and to reduce environmental factors that

produce nausea.

Allow periods of uninterrupted sleep between procedures. Proce-

dures and medication administration sometimes trigger periods of


Offer small amount of cool liquids or ice chips to provide some

fluid to reduce the possibility of dehydration.

Suggest frequent mouth care to reduce unpleasant taste in the


Give dry, bland foods, such as dry toast or crackers, during peri-

ods of nausea to make it possible to eat. These foods have been

found to be effective.

Administer antinausea medications, as prescribed.

Inform:  Teach relaxation techniques and encourage patient to use

these techniques during mealtime to reduce stress and divert atten-

tion from the nausea.

Teach patient how to use food and fluid during periods of nausea

to avoid dehydration and lack of nutrients. Food should be taken in

small, frequent feedings. Avoid drinking with meals.

Attend:  When nausea abates, encourage patient to increase food

intake to assist with adequate intake of nutrients.

Assist patient to make a list of best tolerated and poorly tolerated

foods so he or she can choose quickly and wisely when nausea


Manage:  If nausea persists, refer patient to a nutritionist to assist

after discharge to ensure that adequate nutrients will be ingested.

Stress the importance of follow-up appointments with the physi-

cian. Nausea is a preventable problem and should respond to appro-

priate measures.


Diet Staging; Fluid and Electrolyte Management; Fluid Monitoring;

Medication Management; Nausea Management Nutritional Manage-



Mamaril, M. E., et al. (2006, December). Prevention and management of

postoperative nausea and vomiting: A look at contemporary techniques.
Journal of Perianesthesia Nursing, 21(6), 404–410.




Limitation of independent operation of wheelchair within environment


• Impaired ability to operate a manual or power wheelchair on curbs,

even surfaces, uneven surfaces, and/or an incline or a decline


• Cognitive impairment

• Environmental constraints

• Deconditioning

• Impaired vision

• Deficient knowledge

• Limited endurance

• Depressed mood

• Musculoskeletal impairment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Pharmacological function

• Neurocognition


The patient will

• Have no complications associated with impaired wheelchair mobil-

ity, such as skin breakdown, contractures, venous stasis, thrombus
formation, depression, alteration in health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of independence and safety possible with

regard to wheelchair use.

• Express feelings regarding alteration in ability to use wheelchair.

• Participate in social and occupational activities to the greatest

extent possible.

• Demonstrate understanding of techniques to improve wheelchair



Ambulation: Wheelchair; Balance; Mobility Level; Muscle Function


Determine:  Assess wheelchair status: Seat is wide and deep enough

to support thighs, low enough for feet to touch the floor, yet high

enough to allow easy transfer from bed to chair; the back is tall

enough to support upper body; brakes on wheels lock; and seat belt

is present (may attach at waist, hips, or chest). Assessment ensures

chair meets patient’s physical needs (identifies need for modification),

promotes comfort, and prevents injuries (e.g., falls).

Assess patient’s level of strength in arms, and if chair is easy for

patient to operate when weak. This determines the need for a

motorized wheelchair to help maintain mobility and independence.

Identify patient’s level of independence using the functional mobil-

ity scale. Communicate findings to staff to promote continuity of

care and preserve the documented level of independence.

Monitor and record daily evidence of complications related to

impaired wheelchair mobility. Patients with neuromuscular dysfunc-

tion are at risk for complications.

Assess patient’s skin on return to bed and request a wheelchair

cushion, if necessary, to maintain skin integrity.

Perform:  Perform ROM exercises for affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM as tolerated. This prevents joint contractures and mus-

cle atrophy.

Inform:  Explain to patient location of vulnerable pressure points and

instruct to shift and reposition weight to prevent skin breakdown.

Ensure patient maintains anatomically correct and functional body

positioning to promote comfort.

Demonstrate techniques to promote wheelchair mobility to the

patient and family members and note the date; have them perform a

return demonstration to ensure continuity of care and use of proper


Attend:  Encourage patient to operate her wheelchair independently

to the limits imposed by her condition to maintain muscle tone,

prevent complications of immobility, and promote independence in

self-care and health maintenance skills.

Encourage attendance at physical therapy sessions and reinforce

prescribed activities on the unit by using equipment, devices, and

techniques used in the therapy session. To maintain continuity of

care and promote patient safety.

Manage:  Refer patient to a physical therapist to enhance wheelchair

mobility and rehabilitation of musculoskeletal deficits.

Help patient identify resources for maintaining highest level of

mobility (e.g., community stroke program, sports associations for

people with disabilities, and the National Multiple Sclerosis Society)

to promote reintegration into the community.


Exercise Promotion: Strength Training; Exercise Therapy: Balance;

Exercise Therapy: Muscle Control; Positioning: Wheelchair


Gavin-Dreschnack, D., et al. (2005, April–June). Wheelchair-related falls: Cur-

rent evidence and directions for improved quality care. Journal of Nursing
Care Quality, 20(2), 119–127.




Limitation in independent, purposeful physical movement of the

body or of one or more extremities


• Gait changes, postural instability; difficulty turning

• Limited ROM; ability to perform fine and gross motor skills

• Movement-induced tremor, uncoordinated or jerky movements

• Slowed and/or uncoordinated movements; reaction time.

• Substitution of other behaviors for impaired mobility (for instance,

increased attention to other’s activity and controlling behavior)


• Activity intolerance

• Decreased endurance; muscle

• Altered cellular metabolism

control, mass or strength

• Body mass index above

• Depressive mood state

75th percentile

• Deficient knowledge about

• Cognitive impairment

value of exercise

• Contractures

• Developmental delay

• Cultural beliefs regarding

• Discomfort

age-appropriate activity

• Disuse

• Deconditioning

• Joint stiffness

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition


The patient will

• Maintain muscle strength and joint ROM.

• Be free from complications (e.g., contractures, venous stasis,

thrombus formation, skin breakdown, and hypostatic pneumonia).

• Achieve the highest level of mobility (will transfer independently,

will be wheelchair-independent, or will ambulate with assistive
devices such as walker, cane, and braces).

• Carry out mobility regimen.

• Use resources to help maintain level of functioning.


Ambulation; Ambulation: Wheelchair; Joint Movement: Hip; Joint

Movement: Shoulder; Mobility; Transfer Performance


Determine:  Identify level of functioning using a functional mobility

scale. Communicate patient’s skill level to all staff members to pro-

vide continuity and preserve identified level of independence.

Monitor and record daily any evidence of immobility

complications as they may be more prone to develop complications.


Perform:  Perform ROM exercises to joints, unless contraindicated, at

least once every shift to prevent joint contractures and muscular

atrophy. Turn and reposition patient every 2 hr. Establish a turning

schedule and post at bedside. Monitor frequency of turning to pre-

vent skin breakdown by relieving pressure. Place joints in functional

position. Use trochanter roll along the thigh, abduct thighs, use

high-top sneakers, and pull a small pillow under patient’s head to

maintain joints in a functional position and prevent musculoskeletal


Place items within reach of the unaffected arm if patient has one-

sided weakness or paralysis to promote patient’s independence.

Carry out medical regimen to manage or prevent complications

(e.g., administer prophylactic heparin for venous thrombosis). This

promotes patient’s health and well-being.

Provide progressive mobilization to the limits of patient’s

condition (bed mobility to chair mobility to ambulation) to maintain

muscle tone and prevent complications of immobility.

Inform:  Instruct patient and family members in ROM exercises,

transfers, skin inspection, and mobility regimen to help prepare for

discharge and promote continuity of care. Request return

demonstration to ensure use of proper technique.

Attend:  Help patient use a trapeze and side rails to encourage inde-

pendence in mobility. Instruct him to perform self-care activities to

increase muscle tone.

Encourage physical therapy sessions and support activities on the

unit by using the same equipment and technique. Request written

mobility plans for reference. Ensure all members of the healthcare

team are reinforcing learned skills in the same manner.

Manage:  Refer patient to a physical therapist for development of

mobility regimen to help rehabilitate musculoskeletal deficits.

Assist patient in identifying resources such as American Heart

Association to provide a comprehensive approach to rehabilitation.


Exercise Promotion: Strength Training; Exercise Therapy: Joint

Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair


Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized

elderly. The Canadian Nurse, 101(6), 16–20.

Nursing diagnosis – IMPAIRED BED MOBILITY



Limitation of independent movement from one bed position to another


Impaired ability to perform the following actions while in bed:

• Move from supine to long sitting or long sitting to supine

• Move from supine to prone or prone to supine

• Move from supine to sitting or sitting to supine

• “Scoot” or reposition body

• Turn from side to side


• Cognitive impairment

• Musculoskeletal and/or

• Deconditioning

neuromuscular impairment

• Deficient knowledge

• Obesity

• Environmental constraints

• Pain

• Insufficient muscle strength

• Sedating medications

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Pharmacological function

• Physical regulation


The patient will

• Have no complications associated with impaired bed mobility,

such as altered skin integrity, contractures, venous stasis, thrombus
formation, depression, altered health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of bed mobility possible (independence,

independence with device, verbalization of needs for assistance with
bed mobility, requires assistance of one person or two people).

• Demonstrate ability to use equipment or devices to assist with

moving about in bed safely.

• Adapt to alteration in ability to move about in bed.

• Participate in social, physical, and occupational activities to the

extent possible.


Body Positioning: Self-Initiated; Cognition; Immobility

Consequences: Physiological; Immobility Consequences: Psychocogni-

tive; Joint Movement, Mobility; Neurological Status: Consciousness


Determine:  Identify patient’s level of independence using functional

mobility scale and document findings to provide continuity of care.

Monitor and record daily evidence of complications related to

impaired bed mobility (contractures, venous stasis, skin breakdown,


thrombus formation, depression, altered health maintenance or self-

care skills, falls). Assess patient’s skin every 2 hr to maintain skin


Perform:  Perform ROM exercises to affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM, as tolerated, to prevent joint contractures and muscle


Assist patient in maintaining anatomically correct and functional

body positioning to relieve pressure, thereby preventing skin break-

down and fluid accumulation in dependent extremities. Encourage

repositioning every 2 hr while in bed.

Establish a turning schedule for immobile patient. Encourage pro-

gressive mobility within patient’s limits to maintain muscle tone,

prevent complications, and promote self-care.

If you are uncertain about your ability to move the patient,

request help from colleagues to maintain safety.

Inform:  Instruct patient and family members in techniques to

improve bed mobility and ways to prevent complications to help

prepare the patient and family members for discharge.

Demonstrate patient’s bed mobility regimen and note the date.

Have patient and family members perform a return demonstration

to ensure continuity of care and use of proper technique.

Attend:  Encourage patient to participate in physical and

occupational therapy sessions. Incorporate equipment, devices, and

techniques used by therapists into your care. Request written

instructions from the patient’s therapists to use as a reference to

help ensure continuity of care and reinforce learned skills.

Manage:  Refer patient to a physical therapist to continue improve-

ment in bed mobility and rehabilitate musculoskeletal deficits; and

an occupational therapist to continue to maximize self-care skills.

Assist patient in identifying and contacting resources for social

and spiritual support to promote the patient’s reintegration into the

community and help him maintain psychosocial health.


Bed Rest Care; Body Mechanics Promotion; Exercise Promotion:

Strength Training; Exercise Therapy: Joint Mobility; Exercise Ther-

apy: Muscle Control; Positioning


Lyder, C. H. (2006, August). Assessing risk and preventing pressure ulcers in

patients with cancer. Seminars in Oncology Nursing, 22(3), 178–184.

Nursing diagnosis – IMPAIRED MEMORY



Inability to remember or recall bits of information or behavioral



• Inability to determine whether a behavior was performed

• Inability to learn new skills or information or to perform

previously learned skills

• Inability to recall factual information and recent or past events

• Incidences of forgetting, including forgetting to perform a behavior

at a scheduled time


• Anemia

• Fluid and electrolyte

• Decreased cardiac output


• Excessive environmental

• Hypoxia


• Neurological disturbances

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Emotional

• Self-care

• Fluids and electrolytes


The patient/family will

• Express feelings about memory impairment.

• Acknowledge need to take measures to cope with memory


• Identify coping skills to deal with memory impairment.

• State specific plans to modify lifestyle.

• Establish realistic goals to deal with further memory loss.


Cognition; Cognitive Orientation; Concentration; Memory; Neuro-

logical Status: Consciousness


Determine:  Observe patient’s thought processes during every shift.

Document and report any changes. Changes may indicate progressive

improvement or a decline in patient’s underlying condition.

Perform:  Implement appropriate safety measures to protect patient

from injury. He or she may be unable to provide for his or her own

safety needs.

Call patient by name and tell him or her your name. Provide

background information (place, time, and date) frequently through-

out the day to provide reality orientation. Use a reality orientation

board to visually reinforce reality orientation.

Spend sufficient time with patient to allow her to become comfort-

able discussing memory loss and establish a trusting relationship.

Be clear, concise, and direct in establishing goals to promote max-

imal use of patient’s remaining cognitive skills. Offer short, simple

explanations to patient each time you carry out any medical or

nursing procedure to avoid confusion.

Label patient’s personal possessions and photos, keeping them in

the same place as much as possible, to reduce confusion and create

a secure environment.

Inform:  Inform patient that you are aware of his or her memory loss

and that you will help him or her cope with his or her condition to

bring the issue into the open and help patient understand that your

goal is to help him or her.

Teach patient ways to cope with memory loss (e.g., using a beeper

to remind her when to eat or take medications; using a pillbox

organized by days of the week; keeping lists in notebooks or a

pocket calendar; having family members or friends remind her of

important tasks). Reminders help limit the amount of information

patient must maintain in her memory.

Help patient and family members establish goals for coping with

memory loss. Discuss with family members the need to maintain the

least restrictive environment possible. Instruct them on how to main-

tain a safe home environment for patient. This helps ensure that

patient’s needs are met and promotes his or her independence.

Demonstrate reorientation techniques to family members and pro-

vide time for supervised return demonstrations to prepare them to

cope with patient with memory impairment.

Attend:  Encourage patient to develop a consistent routine for

performing activities of daily living to enhance his self-esteem and

increase his self-awareness and awareness of his environment.

Encourage patient to interact with others to increase social

involvement, which may decline with memory loss.

Encourage patient to express the feelings associated with impaired

memory to reduce the impact of memory impairment on patient’s

self-image and lessen anxiety.

Manage:  Help family members identify appropriate community sup-

port groups, mental health services, and social service agencies to

assist in coping with the effects of patient’s illness or injury.


Anxiety Reduction; Calming Technique; Cerebral Perfusion Promo-

tion; Dementia Management; Fluid and Electrolyte Management;

Memory Training; Neurologic Monitoring; Reality Orientation


Parahoo, K., et al. (2006, June). Expert nurses’ use of implicit memory in the

care of patients with Alzheimer’s disease. Journal of Advanced Nursing,
54(5), 563–571.

Nursing diagnosis – RISK FOR LONELINESS



At risk for experiencing discomfort associated with a desire or need

for more contact with others


• Affectional deprivation

• Physical isolation

• Cathectic deprivation

• Social isolation

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Roles/relationships

• Emotional

• Values/beliefs


The patient will

• Identify feelings of loneliness and express desire to socialize more.

• Identify behaviors that lead to loneliness.

• Identify people who will likely support and accept him.

• Spend time with others.

• Be comfortable in social settings, interact with peers, and receive

support from others.

• Make specific plans to continue involvement with others, such as

through recreational activities or social interaction groups.


Loneliness Severity; Risk Control; Social Involvement; Social Support


Determine:  Work with patient to identify factors and behaviors that

have contributed to loneliness to begin changing behaviors that may

have alienated others.

Help patient identify feelings associated with loneliness. This lessens

the impact of feelings and mobilizes energy to counteract them.

Perform:  Spend sufficient time with patient to allow him to express

his feelings of loneliness to establish trusting relationship.

Work with patient to establish goals for reducing feelings of lone-

liness after he leaves healthcare setting to focus energy on specific


Inform:  Inform patient that assistance is available to help him

express feelings of loneliness and identify ways to increase social

activity to bring issue into open and help patient understand that

you want to help him.

Help patient curb feelings of loneliness by encouraging one-on-one

interaction with others who are likely to accept him (e.g., church

members or patients with similar health problems) to promote feelings

of acceptance and support.

Help patient identify social activities he can initiate, such as

becoming active in a support group or volunteer organization. This

fosters feelings of control and increase social contacts.

Help patient accept that other people may view him differently

because of his illness, and explore ways of coping with their reactions

to help patient learn to cope with stigma associated with illness.

Attend:  Encourage patient to address his needs assertively. By being

assertive, patient assumes responsibility for meeting his needs with-

out anger or guilt.

As patient’s comfort level improves, encourage him to attend

group activities and social functions to promote the use of social


Manage:  Refer patient and family to social service agencies, mental

health center, and appropriate support groups to ensure continued

care and maintain social involvement.


Emotional Support; Socialization Enhancement; Spiritual Support;

Visitation Facilitation; Family Integrity Promotion


Perese, E. F., & Wolf, M. (2005, July). Combating loneliness among persons

with severe mental illness: Social network interventions’ characteristics,
effectiveness, and applicability. Issues in Mental Health Nursing, 6(6),




At risk for liver dysfunction


• Hepatotoxic medications (e.g.,

• Viral infection (e.g., hepatitis

acetaminophen, statins)

A, B, or C, Epstein-Barr)

• HIV coinfection

• Chronic biliary obstruction

• Substance abuse (e.g., alcohol,

and infection


• Nutritional deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Risk management

• Pharmacological function

• Fluids/electrolytes


The patient will

• State effects of environmental and ingested chemicals and

substances on their health and liver function.

• Work with industry managers and with public health officials to

lower or eliminate the presence of environmental chemicals and
substances in their work or living environment.

• Have liver function indicators within normal limits.

• Modify lifestyle and risk behaviors to avoid behaviors leading to

hepatic dysfunction and inflammation.

• Maintain long-term follow-up for chronic illness with healthcare


• Manage concurrent disease processes that impact hepatic function.

• Optimize nutritional intake for needs.

• Acknowledge the impact of medications on hepatic function.

• Observe measures to avoid the spread of infection to self and to



Health-Promoting Behavior; Risk Control—Alcohol; Risk Control—

Drug Use; Safe Home Environment; Substance Addiction



Determine: Assist patient and family to assess workplace and home

environments for potential hepatotoxic substances to increase

patient’s awareness of hazards in the environment and to lower

potential for hepatic injury.

Monitor for clinical manifestations of hepatic inflammation and

dysfunction to notify physician in order to initiate treatment if liver

function is compromised. Clinical manifestations may include

fatigue, depression or mood changes, anorexia, RUQ tenderness,

pruritis, jaundice, bruising, or nontraumatic bleeding.

Monitor customary clinical laboratory tests to alert the healthcare

provider of the status of the immune/inflammatory response, the

degree of hepatic metabolic dysfunction, and the impact of concur-

rent disorders on liver function. Clinical laboratory tests include

complete blood cell (CBC) count:   lower red blood cell count,

elevated WBC (increased immunocyte and inflammatory responses);

basic metabolic panel—altered electrolyte balance, elevated glucose,

elevated blood urea nitrogen and creatinine level, elevated HbA1c;

hepatic plasma markers: elevated liver enzymes (alanine aminotrans-

ferase, aspartate aminotransferase, and    -glutamyltranspeptidase);

positive immunoassays for pathogen and viral antigens; elevated

ammonia; elevated bilirubin; low coagulation factors; low total

protein/albumin; elevated lipid panel.

Perform: Carry out postprocedure measures, as ordered, to identify

and/or minimize complications.

Inform: Teach patient about the following: perform hand hygiene

before and after personal hygiene and care; cover draining and non-

healing wounds; report to care provider; inform others of infectious

condition so that each observes barrier precautions; adhere to

prescribed plan of care and treatment with immune system modifiers

(antibiotics, antivirals, interferon, others); maintain a balanced nutri-

tional diet intake. These measures minimize patient’s risk for self-

infection and spread of infection and allow the patient to help modify

lifestyle to maintain optimum health level for self and for others.

Along with healthcare team, prepare the patient for and later evaluate

the results of liver biopsy and provide explanation to patient and family.

The patient and family need understanding of purpose for and

implications of results obtained from a liver biopsy. This support and

education helps the patient understand rationale for plan of treatment

and genetic counseling for genetically linked hepatic disorders.

Attend: Provide a nonjudgmental attitude toward patient’s lifestyle

choices to promote feelings of self-worth.

Manage: Refer patient to counseling and therapy to address lifestyle

choices and risk behaviors. Modification of behaviors will provide

risk avoidance for drug and alcohol abuse and exposure to body-

substance pathogen infection.


Behavioral Modification; Environment Risk Protection; Infection

Protection; Risk Identification; Risk Identification—Genetic; Self-

Modification Assistance; Sports Injury Prevention; Surveillance


McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis

for disease in adults and children (5th ed., pp. 1413–1428). St. Louis, MO:

Nursing diagnosis – SEDENTARY LIFESTYLE



Reports a habit of life that is characterized by a low physical activ-

ity level


• Chooses a daily routine lacking physical exercise

• Demonstrates physical deconditioning

• Verbalizes preference for activities low in physical activity


• Deficient knowledge of health benefits of physical exercise

• Lack of interest, motivation, resources, and/or training

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Nutrition

• Growth and development

• Risk management

• Knowledge


The patient will

• Maintain independent living status with reduced risk for falling.

• Identify barriers to increasing physical activity level.

• Identify health benefits to increasing physical activity level.

• Increase physical activity and limit inactive forms of diversion,

such as television and computer games.

• Seek professional consultation to develop an appropriate plan to

increase physical activity.

• Identify factors that enhance readiness for sleep.

• Demonstrate readiness for enhanced sleep through the use of

appropriate sleep hygiene measures.

• Have amount of sleep congruent with developmental needs and

experience rapid-eye-movement (REM) sleep.

• Express a feeling of being rested after sleep.

• Increase lean muscle and bone strength and decrease body fat.

• Demonstrate weight control and, if appropriate, weight loss.

• Exhibit enhanced psychological well-being and reduced risk of


• Have reduced depression and anxiety and an improved mood.

• Demonstrate increased ability to perform activities of daily living

within limits of chronic, disabling conditions.


Activity Intolerance; Endurance; Energy Conservation; Health-

Promoting Behavior; Immobility Consequences: Physiologic


Determine: Identify barriers and enhancers to increasing physical

activity, including time management, diet, lifestyle, access to


facilities, and safe environments in which to be active. Breaking

down barriers and building opportunities for activity increase the

probability of consistent physical activity.

Perform: Develop a behavior modification plan based on patient’s

condition, history, and precipitating factors to maximize physical

activity and compliance.

Inform: Instruct patient to keep a daily activity and dietary log to

help him or her achieve a more objective view of his or her behav-


Educate patient about how sedentary lifestyle affects cardiovascu-

lar risk factors (such as hypertension, dyslipidemia,

hyperinsulinemia, insulin resistance) to motivate patient to be more


Teach exercises for increasing strength and endurance to maintain

mobility and prevent musculoskeletal degeneration.

Educate patient about using the bedroom only for sleep or sexual

activity and avoiding other activities such as watching television,

reading, and eating to increase sleep efficiency.

Attend: Provide counseling tailored to patient’s risk factors, needs,

preferences, and abilities to enhance emotional well-being and moti-

vation for physical activity.

Discuss the need for activity that will improve psychosocial well-

being to encourage compliance with activities.

Discuss behavioral risk factors in lack of motivation such as

ingestion of carbohydrates, caffeine, nicotine, alcohol, sedatives, hyp-

notics, and fluid intake, to focus behavior on positive outcomes of

increased physical activity.

Manage: Provide education about community resources available to

increase physical activity to decrease barriers to activity.


Activity Therapy; Energy Management; Teaching: Prescribed Activity/



Zabinski, M. F., et al. (2007, January). Patterns of sedentary behavior among

adolescents. Health Psychology, 26(1), 113–120.




The presence or acquisition of cognitive information related to a

specific topic that is sufficient for meeting health-related goals and

can be strengthened


• Expresses an interest in

• Behaves congruent with


expressed knowledge

• Explains knowledge of

• Describes previous experience


related to other topics

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Risk management

• Knowledge

• Values and beliefs


The patient will

• Identify new sources for enhancing knowledge in the topic of


• Make use of all relevant resources to enhance knowledge.

• Ask questions where new information needs clarification.

• Begin practicing new behaviors gleaned from enhanced knowledge.


Knowledge: Health Promotion


Determine:  Assess current health status; problems, restrictions, limita-

tions; personal habits, such as the use of tobacco, drugs, alcohol con-

sumption, level of knowledge about disease process; communication

skills (verbal and written), degree of motivation to maintain health;

familiarity with technology as a source of learning. Assessment infor-

mation will help identify appropriate interventions.

Perform:  Plan a health maintenance program for the patient and

family members addressing current problems. Developing a plan

with the family will increase the probability of compliance by giving

them information to review each day. Provide the family and patient

with a written copy. A written copy can be posted in the patient’s

home where it is always available for review.

Inform:  Provide books and videos that will help the patient’s quest

for enhanced knowledge. Supplying some materials directly may be

a motivation for the patient to search further.

Direct patient and family to use other sources such as libraries,

the Internet, or professional organizations. An independent search

results in the patient developing confidence in his or her ability to

go much deeper into the area of interest.


Attend: Encourage patient and family to verbalize feelings and con-

cerns related to the knowledge and skills that patient needs. This

promotes greater ease in managing challenging situations.

Demonstrate willingness to repeat instruction and demonstrations

of skills needed by the patient. Repetition will reinforce learning and

give the patient added confidence in his or her ability to comply.

Be available to answer questions and correct misconceptions for

the patient/family to enhance the effectiveness of learning.

Introduce the patient and/or family to individuals who may have

had experience with the health problems in question if that is advis-

able. In many cases, having the opportunity to talk to another per-

son that has coped well with the same problem will provide support

and encouragement to the patient.

Manage:  Refer to social worker/case manager early in the patient’s

hospitalization. This person will begin identifying the types of sup-

port and resources the family and patient will need to prepare for

follow on care.

Refer to social and community resources, such a stroke support

group, and Alzheimer’s family support group, American Cancer

Society. The patient can contact these sources for additional

information as needed.


Discharge Planning; Individual; Learning Enhancement; Learning

Facilitation; Referral; Teaching


Eldh, A. C., et al. (2006, September). Conditions for patient participation and

non-participation in health care. Nursing Ethics, 13(5), 503–514.

Nursing diagnosis – DEFICIENT KNOWLEDGE



Absence or deficiency of cognitive information related to a specific



• Inability to follow through with directions

• Inability to perform well on a test

• Inappropriate or exaggerated behaviors (hysteria, hostility,

agitation, apathy)

• Verbalization of the problem


• Cognitive limitation

• Lack of recall

• Information misinterpretation

• Unfamiliarity with information

• Lack of exposure


• Lack of interest in learning

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Nutrition

• Communication

• Sleep

• Coping

• Values/beliefs

• Knowledge


The patient will

• Communicate desire to understand disease state and need for


• Demonstrate ability to perform new health-related procedures.

• Set realistic learning goals within target dates.

• State intention to make needed modifications in lifestyle.


Cognition; Concentration; Information Processing; Knowledge: Dis-

ease Process; Knowledge; Health Behaviors; Knowledge: Health

Resources; Knowledge: Illness Care; Stress Level


Determine: Determine level of knowledge and skills patient already

possesses about his or her health status; motivation to understand

what is needed to improve health status; obstacles to learning; sup-

port systems; usual coping patterns; beliefs about health and treat-

ment of disease; ethnicity; financial resources. Assessment informa-

tion will assist in identifying appropriate interventions.

Perform: Establish an environment of mutual trust and respect to

enhance learning. Consistency between action and words, combined

with the patient’s self-awareness ability to share this awareness with

others, and receptiveness to new experiences form the basis of a

trusting relationship.

Develop with patient specific learning goals with target dates.

Involving patient in planning meaningful goals encourages


Select teaching strategies that will enhance teaching/learning effec-

tiveness, such as discussion, demonstration, role-playing, and visual

materials. Provide all the equipment needed for the patient to learn.

This reduces frustration, aids learning, and minimizes dependence by

promoting self-care.

Inform: Teach those skills that the patient must incorporate into

daily living. Have patient do return demonstration of each skill to

aid in gaining confidence.

When teaching, go slowly and repeat frequently. Offer small

amounts of information and present it in various ways. By building

cognition, patient will be better able to complete self-care measures.

Include family members.
Demonstrate to family members how each self-care measure is

broken down into simple tasks to enhance patient’s success and fos-

ter a sense of control.

Attend: Encourage family members to participate in and have

patience toward learning process (patient may need to repeat new

skills multiple times) to help create a therapeutic environment after


Manage: Have patient incorporate learned skills into care while still

in the hospital. This allows practice and time for feedback.

Provide patient and/or family with names and telephone numbers

of resource people or community agencies so that care is continuous

and follow-up is possible after discharge.

If financial hardship interferes with the ability of the family to

provide equipment and supplies, offer a referral to a social worker

to improve the family’s access to financial assistance.


Behavior Management; Behavior Modification; Decision-Making

Support; Energy Management; Family Support; Financial Resource

Assistance; Health Education; Healthcare Information Exchange:

Risk Identification; Learning Facilitation; Support System Enhance-

ment; Teaching Procedure/Treatment


Shen, Q., et al. (2006, May–June). Evaluation of a medication education pro-

gram for elderly hospitalized inpatients. Geriatric Nursing, 27(3), 184–192.

Nursing diagnosis – NEONATAL JAUNDICE



The yellow orange tint of the neonate’s skin and mucous membranes

that occurs after 24 hours of life as a result of unconjugated biliru-

bin in the circulation


• Neonate age 1–7 days

• Yellow orange skin

• Yellow sclerae

• Yellow mucous membranes

• Abnormal blood profile (hemolysis; total serum bilirubin   2 mg/dl;

total serum bilirubin in high-risk range on age in hour-specific


• Abnormal weight loss (   7%– 8% in breast-feeding newborn)

• Feeding pattern not well established

• Infant experiences difficulty making transition to extrauterine


• Stool (meconium) passage delayed

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Growth and development

• Fluid and electrolytes

• Nutrition


The neonate will

• Establish effective feeding pattern (breast or bottle) that enhances


• Not experience injury as a result of increasing bilirubin levels.

• Receive bilirubin assessment and screening within the first week of

life to detect increasing levels of serum bilirubin.

• Receive appropriate therapy to enhance bilirubin excretion.

• Receive nursing assessments to determine the risk for severity of



Bowel Elimination; Breast-Feeding Establishment: Infant; Nutritional

Status; Risk Control; Risk Detection


Determine:  Evaluate maternal and delivery history for risk factors

for neonatal jaundice (Rh, ABO, G6PD deficiency, direct Coombs,

prolonged labor, maternal viral illness, medications) to anticipate

which neonates are at higher risk for jaundice.

Perform:  Collect and evaluate laboratory blood specimens as ordered

or per unit protocol to permit accurate and timely diagnosis and

treatment of neonatal jaundice.


Inform: Educate parents regarding newborn care at home in relation

to appearance of jaundice in association with any of the following:

no stool in 48 hr, lethargy with refusal to nurse or bottle feed, less

than 1 wet diaper in 12 hr, abnormal infant behavior. Parent educa-

tion is crucial for the time after the neonate is discharged. Parents

are the major decision makers concerning whether and when to

bring the neonate back for medical and nursing assessments after

being discharged from the hospital.

Attend: Provide caring support to the family if a breast-fed neonate

must receive supplementation. It can be upsetting and result in feel-

ings of inadequacy to a breast-feeding mother for her neonate to

require supplementation.

Manage: Coordinate care and facilitate communication between fam-

ily, nursing staff, pediatrician, and lactation specialist. A multidisci-

plinary approach that includes the family enhances communication

and improves outcomes.


Attachment Promotion; Bottle Feeding; Bowel Management; Breast-

Feeding Assistance; Capillary Blood Sample; Discharge Planning;

Infant Care; Kangaroo Care; Newborn Monitoring; Nutritional

Monitoring; Risk Identification: Childbearing Family; Surveillance;

Teaching: Infant Nutrition; Vital Signs Monitoring


Bhutani, V. K., Johnson, L. H., Schwoebel, A., & Gennaro, S. (2006). A sys-

tems approach for neonatal hyperbilirubinemia in term and near-term new-
borns. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35,




Intracranial fluid dynamic mechanisms that normally compensate for

increases in intracranial volumes are compromised, resulting in

repeated disproportionate increases in intracranial pressure (ICP) in

response to a variety of noxious and nonnoxious stimuli


• Baseline ICP    10 mm Hg

• Disproportionate increase in ICP following single nursing


• Elevated P2 ICP wave form

• Repeated increase of   10 mm Hg for more than 5 min following

external stimuli

• Volume pressure response test variation (volume–pressure ratio

greater than 2, pressure–volume index   10)

• Wide amplitude ICP waveform


• Brain injuries

• Sustained hypotension with

• Decreased cerebral perfusion

intracranial hypertension

• Sustained increased ICP

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac functioning

• Neurocognition

• Comfort

• Pharmacologic function

• Elimination

• Respiratory functioning

• Fluid and electrolytes

• Values/beliefs


The patient will

• Maintain effective breathing pattern and normal ABG levels.

• Show no evidence of fever.

• Modify environment to eliminate noxious stimuli.

• Maintain regular bowel function.

• Maintain skin integrity.

• Remain free of signs and symptoms of infection.

• Not show evidence of neurological compromise.


Electrolyte & Acid–Base Balance; Fluid Balance; Neurological Status:

Consciousness; Wound Healing: Primary Intention


Determine: Assess vital signs, temperature, pulses, heart sounds,

jugular vein distension; electrocardiogram, history of hypertension;

mental status, reflexes, response to pain, papillary size and response

to light; respiratory rate, depth, and pattern of respiration, ABG,

pulse oximetry; monitor ICP wave forms for trends over time. Mon-

itor for damped waves. Assess cerebral perfusion pressure.


Assessment information will assist in identifying appropriate


Perform: Maintain ICP monitoring systems if used. Careful attention

must be paid to ensure that the system is functioning to provide

accurate information. Use sterile technique for dressing changes to

prevent contamination of equipment and infection.

Maintain a patent airway and suction only if needed. Suctioning

stimulates coughing and Valsalva maneuver; Valsalva increases

intrathoracic pressure, decreases cerebral venous drainage, and

increases cerebral blood volume, resulting in increased ICP. Elevate

head of the bed 15 –30   or as ordered, and use sandbags, rolled

towels, or small pillows to keep head in a neutral position. Reposi-

tion patient by using a draw sheet to prevent atrophy. Use minimal

amount of stimuli when caring for the patient. Turn and reposition

patient every 2 hr to prevent atelectasis.

Perform ROM exercises to maintain muscle tone.

Inform: Teach patient and family those aspects of care in which they

can participate without feeling anxious. Instruct family members in

gentle stroking of patient’s face, arms, or hand. Touch by family

members may lower the ICP in some cases.

Attend: Provide nursing care in a calm, reassuring manner. Avoid

discussion of upsetting topics near the bedside. This helps prevent

emotional upset that can increase ICP. Encourage patient and family

to express feelings associated with diagnosis, treatment, and recov-

ery. Expression of feelings helps patient and family cope with treat-


Manage: Arrange for frequent multidisciplinary/family care

conference in order to keep care goal-oriented. Refer patient and

family to support group to help deal with the injury, diagnosis, or

recovery. Refer to social worker/case manager for follow-up care,

home assessment, home visits, and referral to community agencies.


Acid–Base Management; Bedside Laboratory Testing; Cerebral

Edema Management; Fluid–Electrolyte Management; ICP Monitoring


Littlejohns, L., & Bader, M. K. (2005, October–December). Prevention of sec-

ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),

Nursing diagnosis – INSOMNIA



A disruption in the amount and quality of sleep that impairs func-



• Observed changes in affect

• Reports difficulty falling asleep

• Observed lack of energy, diffi-

and staying asleep

culty concentrating

• Reports dissatisfaction with

• Increased work or school



• Reports early morning awak-

• Reports changes in mood


• Reports decreased health status,

• Reports nonrestorative sleep

quality of life


• Activity pattern

• Grief

• Anxiety

• Inadequate sleep hygiene

• Depression

• Intake of stimulants

• Environmental factors

• Intake of alcohol

• Fear

• Medication

• Gender-related hormonal shifts

• Physical discomfort

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Sleep/rest

• Emotional

• Values/beliefs


The patient will

• Identify factors that prevent or promote sleep.

• Achieve sleep for ___ hours without interruption.

• Report feeling well-rested.

• Be free from signs of sleep deprivation.

• Alter diet and habits to promote sleep, such as reducing caffeine

and alcohol intake before bedtime.

• Not exhibit sleep-related behavioral symptoms, such as

restlessness, irritability, lethargy, and disorientation.

• Perform relaxation exercises at bedtime.


Anxiety Level; Fear Level; Mood Equilibrium; Personal Well-Being;



Determine: Assess patient’s daytime activity and work patterns;

travel history; normal bedtime; problems associated with sleep; qual-

ity of sleep; sleeping environment; personal beliefs about sleep; use

of alcohol, caffeine, hypnotics, and nicotine. Assessment information

will assist in selecting appropriate interventions.


Perform: Ask patient to help make changes in the environment that

would promote sleep. This allows patient to have an active role in


Administer medications on a schedule that will allow for

maximum rest. Disturbing for medication administration during rest

periods will disrupt sleep patterns. If the patient requires diuretics

in the evening, give far enough in advance to allow peak effect

before bedtime. Other medications that may interfere with sleep are

-blockers, MAO inhibitors, and phenytoin.

Provide patient with sleep aids, such as pillows, bath before sleep,

food or drink, and reading materials to promote ease in falling

asleep. Milk and some high-protein snacks, such as cheese and nuts,

contain   L-tryptophan, a sleep promoter. Personal hygiene and

prebedtime rituals promote sleep in some patients.

Develop a sleep log with the patient describing sleep disturbances

and the effect on daytime functioning. The log will help both

patient and nurse to evaluate progress in evaluating sleep patterns.

Inform: Teach patient relaxation techniques such as guided imagery,

deep breathing, meditation, aromatherapy, and progressive muscle

relaxation. Practice with the patient at bedtime. Purposeful

relaxation efforts usually help promote sleep.

Instruct patient to eliminate or reduce caffeine and alcohol intake

and avoid foods that interfere with sleep (e.g., spicy foods). Foods

and beverages containing caffeine consumed fewer than 4 hr before

bedtime may interfere with sleep. Alcohol disrupts normal sleep,

especially when ingested immediately before retiring.

When anxiety is a factor in sleep deprivation, teach coping tech-

niques to reduce the frustration of being unable to sleep.

Attend: Listen to the patient’s description of insomnia. Allow time for

the patient to talk about his frustration. Being able to have a sensitive

listener may help reduce some of the frustration and may lead to new

ideas about how to help the patient resolve his sleep issues.

Ask the patient each day to describe the quality of his sleep. Patients

are sometimes unaware of the periods in which they do sleep.

Manage: Refer to case manager/social worker to ensure that follow-

up is provided.


Biofeedback; Calming Techniques; Coping Enhancement; Energy

Management; Security Enhancement; Simple Relaxation Therapy;

Sleep Enhancement


Holcomb, S. S. (2006, February). Recommendations for assessing insomnia.

The Nurse Practitioner, 3(2), 55–60.





At risk for inadvertent anatomical and physical changes as a result

of posture on equipment used during an invasive/surgical procedure


• Disorientation

• Muscle weakness

• Edema

• Obesity

• Emaciation

• Sensory–perceptual

• Immobilization

disturbances from anesthesia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Fluid/electrolytes

• Risk management

• Pharmacological function


The patient will

• Maintain effective breathing patterns.

• Maintain adequate cardiac output.

• Have surgical positioning that facilitates gas exchange.

• Not show evidence of neurologic, musculoskeletal, or vascular


• Maintain tissue integrity.


Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-

logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue

Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral


Determine: Document and report the results of the preoperative

nursing assessment. Identify factors predisposing patient to tissue

injury. This information guides interventions.

Perform: Use the appropriate mode of patient transportation

(stretcher, patient bed, wheelchair, or crib) to ensure patient safety.

Make sure an adequate number of staff members assist with

transferring patient—obtain at least two for moving patient onto an

operating room bed and at least four for moving anesthetized

patient off operating room bed. Adequate staffing enhances safety.

Check the operating room bed before surgery for proper function-

ing. Intraoperative bed malfunction can result in increased anesthe-

sia time and a more difficult surgical approach.

Ensure proper positioning (follow institutional policies):
– Check patient’s neck and spine for proper alignment to avoid
– Check that patient’s legs are straight and ankles uncrossed.
Crossed ankles cause pressure on tissue, vessels, and nerves.

–  Place a safety strap 29 (5 cm) above patient’s knees, tight
enough to restrain without compromising superficial venous
return. Applied too tightly, the safety strap may cause venous
thrombosis or compression of tibial, peroneal, or sciatic nerves.
–  Secure patient’s arms at his sides with a draw sheet, with palms
down, making sure that no part of the arm or hand extends
over the mattress. Hyperextension can cause injury to the
brachial plexus. Supination of palms minimizes pressure.
Apply eye pads if patient’s eyelids don’t remain closed or if

surgery is being performed on his head, neck, or chest. If allowed to

remain open, the eyes may dry out and become infected. Corneal

abrasions may result from drapes and other foreign material rubbing

against the eyes.

If surgery is expected to last more than 2 hr or if patient is pre-

disposed to a pressure injury, place padding under his occiput,

scapulae, olecranon, sacrum, coccyx, and calcaneus to protect poten-

tial pressure points. Apply a padded footboard to support patient’s

feet. Avoid plantarflexion, and prevent stretching of the tibial nerve

and subsequent foot drop.

Assess patient position following each positional change to ensure

proper body alignment and adequate padding and support.

Inform: Tell patient about positioning measures planned to reduce

preoperative anxiety.

Attend: Assure patient that careful positioning of the body will be

carried to reduce worry about possible injury.

Manage: Consult with a physical or occupational therapist if special

protective equipment is needed to ensure safety for the patient.


Circulatory Care: Mechanical Assist Device, Circulatory

Precautions; Infection Control: Intraoperative; Positioning: Intraoper-

ative; Skin Surveillance; Surgical Precautions; Temperature

Regulation: Intraoperative


Millsaps, C. C. (2006, January). Pay attention to patient positioning! RN,

69(1), 59–63.

Nursing diagnosis – RISK FOR INJURY


At risk for injury as a result of environmental conditions interacting

with the individual’s adaptive and defensive resources




• Biological: Community immu-

• Abnormal blood profile:

nization level; microorganisms

Altered clotting factors;

• Chemical: Cosmetics; drugs,

decreased hemoglobin; leuko-

pharmaceutical agents; dyes;
alcohol, nicotine, preservatives;

cytosis/leucopenia; sickle cell;
thalassemia; thrombocytopenia
• Biochemical dysfunction

• Human: Nosocomial agents;

• Immune or autoimmune

staffing patterns; cognitive,
affective, psychomotor factors

• Developmental age: physiologi-

• Nutritional: Food types,

cal and/or psychosocial


• Tissue hypoxia

• Physical: Design, structure, and

arrangement of community,
building, and/or equipment

• Mode of transport

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Emotional

• Risk management


The patient will

• Acknowledge presence of environmental hazards in their everyday


• Take safety precautions in and out of home.

• Instruct children in safety habits.

• Childproof house to ensure safety of young children and

cognitively impaired adults.


Immune Status; Risk Control; Safety Behavior: Home Physical Envi-

ronment; Safety Behavior: Personal; Safety Status: Falls Occurrence;

Safety Status: Physical Injury


Determine: Help patient identify situations and hazards that can

cause accidents to increase patient’s awareness of potential dangers.

Perform: Arrange environment of patient with dementia to minimize

risk of injury:

–  Place furniture against walls.
–  Avoid use of throw rugs.

Maintain lighting so that patient can find her way around room

and to bathroom. Poor lighting is a major cause of falls.

Prevent iatrogenic harm to hospitalized patient by following the

2007 National Patient Safety goals. This resource provides compre-

hensive measures designed to prevent harm.

Follow agency policy regarding the use of restraints—they are

generally used as a last resort after other measures have failed.

Agency policies will provide clear direction to use restraints safely.

Inform: Encourage adult patient to discuss safety rules with children

to foster household safety. For example:

–  Don’t play with matches.
–  Use electrical equipment carefully.
–  Know location of the fire escape route.
–  Don’t speak to strangers.
–  Dial 911 in an emergency.

Attend: Encourage patient to make repairs and remove potential

safety hazards from environment to decrease possibility of injury.

Manage: Refer patient to appropriate community resources for more

information about identifying and removing safety hazards. This

enables patient and family to alter environment to achieve optimal

safety level.


Environmental Management: Safety; Fall Prevention; Health Educa-

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