Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION

Risk for alteration in integration and modulation of the physiologi-

cal and behavioral systems of functioning (such as autonomic,

motor, state-organizational, self-regulatory, and attentional–interac-

tional systems)

RISK FACTORS

• Environmental overstimulation

• Oral or motor problems

• Invasive or painful procedures

• Pain

• Lack of containment or

• Prematurity

boundaries

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Identify factors that place infant at risk for behavioral disturbance.

• Identify potential signs of behavioral disturbance in infant.

• Identify appropriate ways to interact with infant.

• Identify their reactions to infant (including ways of coping with

occasional frustration and anger).

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to sensory information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1 Month, 2 Months, 4 Months,

6 Months, and 12 Months; Infant Care; Neurological Status;

Knowledge: Parent–Infant Attachment; Parenting; Preterm Infant

Organization; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant to help parents identify and interpret the infant’s behavioral

cues and respond appropriately. For example, help them recognize

when the infant is awake and alert, and help them understand

when the infant needs more stimulation, such as being spoken to

or held.

197

Inform: Explain to parents that infant maturation is a developmental

process and that their participation is crucial to their understanding

of the importance of nurturing the infant. Participation in the

process by the parents will both stimulate the developmental process

and alert to delays in development.

Explain to parents that their actions can help modify some of

their infant’s behavior; however, make it clear that infant maturation

isn’t completely within their control. This explanation may decrease

the parent’s feelings of incompetence.

Explain to parents that certain risk factors may interfere with the

infant’s ability to achieve optimal development. These risk factors

include overstimulation, lack of stimulation, lack of physical contact,

and painful medical procedures. Educating the parents will help

them understand their role in interpreting the infant’s behavioral

cues and providing appropriate stimulation.

Describe for the parents the potential signs of a behavioral distur-

bance in the infant: inappropriate responses to stimuli, such as the

failure to respond to human contact or tendency to become agitated

with human contact; physiologic regulatory problems, such as a

breathing disturbance in a premature infant; and apparent inability

to interact with the environment. Education will help the parents

recognize if the infant has a problem in behavioral development.

Attend: Explore with parents ways to cope with the stress imposed

by the infant’s behavior to increase their coping skills. Help parents

identify their emotional responses to the infant’s behavior to help

them recognize and adjust their response patterns. Explain that it is

normal for parents to experience feelings of inadequacy, frustration,

or anger if the infant does not respond positively to them.

Praise the parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide the parents with information on sources of support

and special infant services to help them cope with the infant’s long-

term needs.

SUGGESTED NIC INTERVENTIONS

Attachment Process, Infant Care; Newborn Monitoring; Parent

Education: Infant; Positioning; Surveillance

Reference

Swartz, M. K. (2005, March–April). Parenting preterm infants: A meta-

synthesis. The American Journal of Maternal Child Nursing, 30(2),
115–120.

Nursing diagnosis – DISORGANIZED INFANT BEHAVIOR

DISORGANIZED  INFANT  BEHAVIOR

DEFINITION

Disintegrated physiological and neurobehavioral responses of infant

to the environment

DEFINING CHARACTERISTICS

• Attention–interaction system—abnormal response to sensory stimuli

(e.g., difficulty soothing, inability to sustain alert status)

• Motor-system—altered primitive reflexes; finger splaying; jittery,

uncoordinated movement; increased or decreased tone; startles,
tremors, or twitches

• Physiological—arrhythmias, bradycardia, or tachycardia; desatura-

tion; feeding intolerances; skin color changes

• Regulatory problems—inability to inhibit startle; irritability

• State-organizational system—active or quiet awake; diffuse sleep

RELATED FACTORS

• Caregiver—Cue knowledge

• Postnatal—feeding intolerance;

deficit; cue misreading; environ-
mental stimulation contribution

invasive procedures; malnutri-
tion; motor and/or oral prob-

• Environmental—physical envi-

lems; pain; prematurity

ronment inappropriateness;
sensory deprivation, inappro-
priateness, or overstimulation

• Prenatal—congenital or genetic
disorders; teratogenic exposure

• Individual—gestational or

postconceptual age; illness;
immature neurological system

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Learn to identify and understand infant’s behavioral cues.

• Identify their own emotional responses to infant’s behavior.

• Identify means to help infant overcome behavioral disturbance.

• Identify ways to improve their ability to cope with infant’s

responses.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Begin to show appropriate signs of maturation.

SUGGESTED NOC OUTCOMES

Knowledge: Infant Care; Mobility; Neonate; Neurological Status;

Preterm Infant Organization; Sleep Thermoregulation

195

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures

Inform: Explain to parents that infant maturation is a developmental

process. Their participation is crucial to help them understand the

importance of nurturing the infant.

Explain to parents that their actions can help modify some of

infant’s behavior; however, make it clear that infant maturation isn’t

completely within their control. This explanation may help decrease

the parents’ feelings of incompetence.

Explain to parents that infant gives behavioral cues that indicate

needs. Discuss appropriate ways to respond to behavioral cues—for

example, providing stimulation that doesn’t overwhelm the infant;

stopping stimulation when the infant gives behavioral cues (such as

yawning, looking away, or becoming agitated); and finding methods

to calm the infant if she becomes agitated (such as swaddling, gentle

rocking, and quiet vocalizations). Monitoring responses aids in gaug-

ing effectiveness of meeting needs.

Help parents identify and cope with their responses to infant’s

behavioral disturbance to help them recognize and adjust their

response patterns. When the infant doesn’t respond positively, the

parents may feel inadequate or become frustrated. They need to

understand that these reactions are normal.

Attend: Explore with parents ways to cope with stress imposed by

infant’s behavior to help them develop better coping skills.

Praise parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to promote coping with infant’s long-term

needs.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Neurologic Monitoring; Newborn

Care; Parent Education: Infant; Positioning; Sleep Enhancement

Reference

Beal, J. A. (2005, November–December). Evidence for best practices in the

neonatal period. The American Journal of Maternal Child Nursing, 30(6),
397–403.

Nursing diagnosis – RISK FOR URGE URINARY INCONTINENCE

RISK  FOR  URGE  URINARY  INCONTINENCE

DEFINITION

At risk for involuntary loss of urine associated with a sudden,

strong sensation or urinary urgency

RISK FACTORS

• Effects of medication, caffeine,

• Detrusor muscle instability

or alcohol

with impaired contractility

• Detrusor hyperreflexia from

• Ineffective toileting habits

cystitis, urethritis, tumors,
renal calculi, central nervous
system disorders above
pontine micturation center

• Involuntary sphincter
relaxation
• Small bladder capacity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• State ability to anticipate if incontinence is likely to occur.

• State understanding of potential causes of urge incontinence and

its treatment.

• Avoid or minimize complications of urge incontinence.

• Discuss potential effects of urologic dysfunction on self and family

members.

• Demonstrate skill in managing incontinence.

• Identify community resources to cope with alterations in urinary

status.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Urinary Continence; Urinary Elimi-

nation

INTERVENTIONS AND RATIONALES

Determine:  Observe patient’s voiding pattern, and document intake

and output to ensure correct fluid replacement therapy and provide

information about the patient’s ability to void adequately.

Determine patient’s premorbid elimination status to ensure that inter-

ventions are realistic and based on the patient’s health status and goals.

Assess patient’s ability to sense and communicate elimination

needs to maximize self-care.

Perform:  Unless contraindicated, provide 21⁄2 to 3 qt (2.5–3 L) of

fluid daily to moisten mucous membranes and ensure adequate

hydration. Space out fluid intake through the day and limit it to

150 ml after supper to reduce the need to void at night.

Place commode next to bed, or assign patient bed next to

bathroom. A bedside commode or convenient bathroom requires less

193

energy expenditure than bedpan. If using commode, keep bed and

commode at same level to facilitate patient’s movements. If using

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

that is warm, clean, and free from odors to promote continence.

Have patient wear easily removed articles of clothing (a gown

instead of pajamas, Velcro fasteners instead of buttons or zippers)

to facilitate the removal of clothing and foster independence.

Have patient keep a diary recording episodes of incontinence to

use as a basis for planning bladder training interventions; interven-

tions may include voiding every 2 hr, avoiding high fluid intake,

maintaining proper hygiene, or notifying a healthcare professional if

urge incontinence occurs frequently. Individualized interventions help

promote self-care, foster motivation, and avoid incontinence.

Incorporate patient’s suggestions for managing incontinent

episodes into a care plan to foster motivation.

Inform:  Explain urge incontinence to patient and family members,

especially preventive measures and potential underlying causes, to

foster compliance.

Instruct patient to stop and take a deep breath if he or she expe-

riences an intense urge to urinate before he can reach a bathroom.

Anxiety and rushing may increase bladder contraction.

Attend:  Encourage patient to express feelings about incontinence to

provide emotional support and identify needed areas for further

patient teaching.

Manage:  Use an interdisciplinary approach to caring for incontinence.

Incorporate recommendations from a urologist, urology nurse special-

ist, other healthcare providers, and the patient. Monitor progress and

report the patient’s response to interventions. An interdisciplinary

approach helps ensure that the patient receives adequate care. Encour-

aging patient participation on the team will help foster motivation.

Note if patient expresses concern about the effect of incontinence

on sexuality. If appropriate, refer him to a sex therapist to promote

sexual health.

Refer patient and family members to community resources such as

support groups, as appropriate, to help ensure continuity of care.

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Urinary Elimination Management; Urinary Habit

Training; Urinary Incontinence Care

Reference

Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary

continence in hospitalized older people? An exploratory study. Journal of
Clinical Nursing, 15(10), 1276–1286.

Nursing diagnosis – URGE URINARY INCONTINENCE

URGE  URINARY  INCONTINENCE

DEFINITION

Involuntary passage of urine occurring shortly after a strong sense

of urgency to void

DEFINING CHARACTERISTICS

• Bladder contraction or spasm

• Increased or decreased volume

• Frequency

• Nocturia

• Inability to reach toilet in time

• Urgency

RELATED FACTORS

• Alcohol intake

• Decreased bladder capacity

• Atrophic urethritis

• Detrusor hyperactivity with

• Atrophic vaginitis

impaired bladder contractility

• Bladder infection

• Fecal impaction

• Caffeine intake

• Use of diuretics

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Have fewer episodes of incontinence.

• State increased comfort.

• State understanding of treatment.

• Have minimal, if any, complications.

• Discuss impact of disorder on himself and family members.

• Demonstrate skill in managing incontinence.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe voiding pattern; document intake and output.

This ensures correct fluid replacement therapy and provides informa-

tion about patient’s ability to void adequately.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient should receive adequate care and take part in decisions

about care as much as possible.

Assist with specific bladder elimination procedures, such as the

following:

bladder training—place patient on commode every 2 hr while

awake and once during night, provide privacy, and gradually

increase intervals between toileting (these measures aim to restore a

regular voiding pattern). As well as rigid toilet regimen—place

patient on toilet at specific times (to aid adaptation to routine

191

physiologic function), and keep baseline micturition record for

3–7 days (to monitor toileting effectiveness).

Administer pain medication; discuss effectiveness with patient to

reinforce that pain can be alleviated, which reduces tension and anxiety.

Place commode next to bed, or assign patient bed next to

bathroom. A bedside commode or convenient bathroom requires less

energy expenditure than bedpan. If using commode, keep bed and

commode at same level to facilitate patient’s movements. If using

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

that is warm, clean, and free from odors to promote continence.

Provide a clock to help patient maintain voiding schedule through

self-monitoring.

Unless contraindicated, maintain fluids to 3,000 ml daily to mois-

ten mucous membranes and ensure hydration; limit patient to 150

ml after dinner to reduce need to void at night.

Have patient wear easily removable clothes (gown instead of paja-

mas and Velcro fasteners instead of buttons or zippers) to reduce

frustration and delay in voiding routine.

If patient loses control on way to bathroom, instruct patient to

stop and take a deep breath. Anxiety and rushing may strengthen

bladder contractions.

Inform: Explain urologic condition to patient and family members;

include instructions on preventive measures and established bladder

schedule. Patient education begins with educational assessment and

depends on establishing a therapeutic relationship with patient and

family. Prepare patient for discharge according to individual needs to

allow patient to practice under supervision.

Instruct patient and family members on continence techniques for

home use. This reduces fear and anxiety resulting from lack of knowl-

edge of patient’s condition and reassures patient of continuing care.

Attend: Encourage patient to express feelings and concerns related to

his or her urologic problem to identify patient’s fears.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Perineal Care; Self-Care Assistance: Toileting; Uri-

nary Elimination Management; Urinary Habit Training; Urinary

Incontinence Care

Reference

Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary

continence in hospitalized older people?: An exploratory study. Journal of
Clinical Nursing, 15(10), 1276–1286.

Nursing diagnosis – STRESS URINARY INCONTINENCE

STRESS  URINARY  INCONTINENCE

DEFINITION

Sudden leakage of urine with activities that increase intra-abdominal

pressure

DEFINING CHARACTERISTICS

• Dribbling with increased abdominal pressure

• Frequency

• Urgency

RELATED FACTORS

• Degenerative changes in pelvic

• Intrinsic urethral sphincter

muscles

deficiency

• High intra-abdominal pressure

• Weak pelvic muscles

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain continence.

• State increased comfort.

• State understanding of treatment.

• State understanding of surgical procedure.

• Demonstrate skill in managing urinary elimination problems.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe patient’s voiding patterns, time of voiding,

amount voided, and whether voiding is provoked by stimuli. Accu-

rate, thorough assessment forms basis of an effective treatment plan.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient expects to receive adequate care and to participate in

decisions regarding care.

Help patient to strengthen pelvic floor muscles by Kegel exercises

for sphincter control. Exercises increase muscle tone and restore cor-

tical control.

Promote patient’s awareness of condition through education to

help patient understand illness as well as treatment.

Help patient reduce intra-abdominal pressure by losing weight,

avoiding heavy lifting, and avoiding chairs or beds that are too high

189

or too low. These measures reduce intra-abdominal pressure and

bladder pressure.

Provide supportive measures:
– Respond to call bell quickly, assign patient to bed next to bath-

room, put night-light in bathroom, and have patient wear easily

removable clothing (gown rather than pajamas and Velcro fasteners

rather than buttons or zippers). Early recognition of problems pro-

motes continence; easily removed clothing reduces patient frustration

and helps achieve continence.

– Provide privacy during toileting to reduce anxiety and promote

elimination.

– Have patient empty bladder before meals, at bedtime, and

before leaving accessible bathroom area to promote elimination,

avoid accidents, and help relieve intra-abdominal pressure.

– Limit fluids to 150 ml after dinner to reduce need to void at

night.

– Encourage high fluid intake, unless contraindicated, to moisten

mucous membranes and maintain hydration.

– Suggest patient eat increased amount of salty food before going

on a long trip (unless contraindicated). Increased sodium decreases

urine production.

– Make protective pads available for patient’s undergarments, if

needed, to absorb urine, protect skin, and control odors.

If surgery is scheduled, give attentive, appropriate preoperative

and postoperative instructions and care to reduce patient’s anxiety

and build trust in caregivers.

Inform: Alert patient and family members about need for toilet

schedule. Prepare for discharge according to individual needs to

ensure that patient will receive proper care.

Attend: Encourage patient to express feelings and concerns related to

urologic problems. This helps patient focus on specific problem.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Teaching: Individual; Urinary Elimination

Management; Urinary Habit Training; Urinary Incontinence Care

Reference

Anders, K. (2006, May). Recent developments in stress urinary incontinence in

women. Nursing Standard, 20(35), 48–54.

Nursing diagnosis – REFLEX URINARY INCONTINENCE

REFLEX  URINARY  INCONTINENCE

DEFINITION

Involuntary loss of urine at somewhat predictable intervals when a

specific bladder volume is reached

DEFINING CHARACTERISTICS

• Complete emptying (with lesion above pontine micturition center)

or incomplete emptying (with lesion above sacral micturition
center) of bladder

• Either inability to sense full bladder, urge to void, or voiding, or

ability to sense urge to void without ability to voluntarily inhibit
bladder contraction

• Inability to voluntarily inhibit or initiate voiding

• Predictable pattern of voiding

• Sensations associated with full bladder (sweating, restlessness, and

abdominal discomfort)

RELATED FACTORS

• Tissue damage (e.g., radiation therapy)

• Neurological impairment above level of pontine or sacral micturi-

tion center

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain fluid balance, with intake approximately equaling output.

• Have minimal, if any, complications.

• Achieve urinary continence.

• Demonstrate skill in managing urinary incontinence.

• Discuss impact of incontinence on himself and family.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Nutritional Status: Food & Fluid

Intake; Tissue Integrity: Skin & Mucous Membranes; Urinary Conti-

nence; Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor intake and output to ensure correct fluid

replacement therapy. Report output greater than intake.

Perform: Implement and monitor effectiveness of specific bladder

elimination procedure, such as the following:

– Stimulate reflex arc. Patient who voids at somewhat predictable

intervals may be able to regulate voiding by reflex arc stimulation. Trig-

ger voiding at regular intervals (e.g., every 2 hr) by stimulating skin of

abdomen, thighs, or genitals to initiate bladder contractions. Avoid

187

stimulation at nonvoiding times. Stimulate primitive voiding reflexes by

giving patient water to drink while he sits on toilet or pouring water

over perineum. External stimulation triggers bladder’s spastic reflex.

– Apply external catheter according to established procedure and

maintaining patency. Observe condition of perineal skin and clean

with soap and water at least twice daily. Cleanliness prevents skin

breakdown and infection. External catheter protects surrounding

skin, promotes accurate output measurement, and keeps patient dry.

Applying foam strip in spiral fashion increases adhesive surface and

cuts risk of impaired circulation.

– Insert indwelling catheter. Monitor patency and keep tubing free

from kinks to avoid drainage pooling and ensure accurate therapy. Keep

drainage bag below level of bladder to avoid urine reflux into bladder.

Perform catheter care according to established procedure. Maintain

closed drainage system to prevent bacteriuria. Secure catheter to leg

(female) or abdomen (male) to avoid tension on bladder and sphincter.

– Apply suprapubic catheter. Change dressing according to estab-

lished procedure to avoid skin breakdown. Monitor patency and

keep tubing free from kinks to avoid drainage pooling in loops of

catheter. Keep drainage bag below bladder level to avoid urine reflux

into bladder. Maintain closed drainage system to prevent bacteriuria.

– Change wet clothes to prevent patient from becoming

accustomed to wet clothes.

Inform: Instruct patient and family members on continence

techniques to use at home. Have patient and family members return

demonstrations until they can perform procedure well. Patient edu-

cation begins with assessment and depends on nurse’s therapeutic

relationship with patient and family.

Attend: Encourage high fluid intake (3,000 ml daily, unless

contraindicated) to stimulate micturition reflex. Limit fluid intake

after 7 p.m. to prevent nocturia.

Encourage patient and family members to share feelings and con-

cerns regarding incontinence. A trusting environment allows nurse to

make specific recommendations to resolve patient’s problems.

Manage: Refer patient and family members to psychiatric liaison

nurse, home healthcare agency, support group, or other resources, as

appropriate. Community resources typically provide healthcare not

available from other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Urinary Bladder Training; Urinary Elimina-

tion Management; Urinary Incontinence Care

Reference

Zarowitz, B. J., & Ouslander, J. G. (2006, September–October). Management

of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265–270.

Nursing diagnosis – OVERFLOW URINARY INCONTINENCE

OVERFLOW  URINARY  INCONTINENCE

DEFINITION

Involuntary loss of urine associated with overdistention of the bladder

DEFINING CHARACTERISTICS

• Bladder distention

• High postvoid residual volume

• Nocturia

• Reported and observed involuntary leakage of small volumes of

urine

RELATED FACTORS

• Bladder outlet obstruction

• Severe pelvic prolapse

• Detrusor external sphincter

• Side effects of anticholinergic,

dyssynergia

calcium channel blocker, or

• Detrusor hypocontractility

decongestant medications

• Fecal impaction

• Urethral obstruction

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Void 200–300 mL of clear, yellow urine every 3–4 hr while

awake.

• Have postvoid residual of less than 50 ml.

• Have reduction in urinary incontinence episodes or complete

absence of urinary incontinence.

• Experience relief of most bothersome aspect of urinary

incontinence.

• Remain clean and dry without urine odor.

• Express understanding of condition and activities to prevent/reduce

overflow incontinence.

• Express improvement in quality of life.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Urinary Continence

INTERVENTIONS AND RATIONALES

Determine: Monitor and record patient’s voiding patterns to

determine existence and extent of overflow incontinence.

Monitor and record patient’s intake and output to determine fluid

balance.

Perform: Ask patient to keep a bladder diary of continent and incon-

tinent voids to promote understanding of the extent of the problem

of overflow incontinence. Discuss voiding and fluid intake patterns.

Accurate understanding of patient’s pattern provides a baseline for

introducing new activities.

185
Provide privacy and adequate time to void to decrease anxiety

and promote relaxation of sphincter.

Assist patient to assume usual position for voiding. Some patients

are unable to void while lying in bed and may develop urinary

retention and overflow incontinence.

Massage (credé) the bladder area during urination to increase

pressure in the pelvic area to encourage drainage of urine from the

bladder.

Institute indwelling or intermittent catheterization, as ordered.

Catheterization is used as a last resort to empty the bladder prevent-

ing overflow incontinence.

Assist with application of pads and protective garments (used only

as a last resort) to prevent skin breakdown and odor and to

promote social acceptance.

Inform: Teach patient and/or family to catheterize patient with

chronic overflow incontinence related to urinary retention using

clean technique to manage long-term overflow incontinence.

Teach stress management and relaxation techniques. Stress and

anxiety interfere with sphincter relaxation, causing urinary retention

and overflow incontinence.

Attend: Encourage patient to share feelings related to incontinence to

reduce anxiety.

Encourage patient to drink six to eight glasses of noncaffeinated,

nonalcoholic, and noncarbonated liquid, preferably water, per day

(unless contraindicated). 1,500–2000 mL/day promotes optimal renal

function and flushes bacteria and solutes from the urinary tract.

Caffeine and alcohol promote diuresis and may contribute to excess

fluid loss and irritation of the bladder wall.

Encourage patient to respond to the urge to void in a timely man-

ner. Ignoring the urge to urinate may cause incontinence.

Encourage patient to participate in regular exercise, including

walking and modified sit-ups (unless contraindicated). Weak abdomi-

nal and perineal muscles weaken bladder and sphincter control.

Encourage patient to avoid anticholinergics, opioids, psychotrop-

ics,    -adrenergic agonists,    -adrenergic agonists, and calcium-

channel blockers (unless contraindicated), which inhibit relaxation of

the urinary sphincter and cause urinary retention.

Manage: Provide referrals for physical therapy or psychological

counseling as necessary to enhance success.

SUGGESTED NIC INTERVENTIONS

Urinary Incontinence Care; Urinary Retention Care

Reference

DuBeau, C. (2006). Clinical presentation and diagnosis of urinary

incontinence. Retrieved December 12, 2006, from http://www.uptodate.com

Nursing diagnosis – FUNCTIONAL URINARY INCONTINENCE

FUNCTIONAL  URINARY  INCONTINENCE

DEFINITION

Inability of usually continent person to reach toilet in time to avoid

unintentional loss of urine

DEFINING CHARACTERISTICS

• Amount of time needed to reach toilet exceeding length of time

between sensing urge to void and uncontrolled voiding

• Loss of urine before reaching toilet

• May be incontinent only in the morning

• Able to empty bladder completely

RELATED FACTORS

• Altered environmental factors

• Psychological factors

• Impaired cognition

• Weakened supporting pelvic

• Impaired vision

structures

• Neuromuscular limitations

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Void at appropriate intervals.

• Have minimal, if any, complications.

• Demonstrate skill in managing incontinence.

• Discuss impact of incontinence on him and family members.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Coordinated Movement; Self-Care: Toileting; Symptom Control;

Urinary Continence; Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor and record patient’s voiding patterns to ensure

correct fluid replacement therapy.

Perform: Stimulate patient’s voiding reflexes (give patient drink of

water while on toilet, stroke area over bladder, or pour water over

perineum) to trigger bladder’s spastic reflex. Provide hyperactive

patient with distraction, such as a magazine, to occupy attention

while on toilet, reduce anxiety, and ease voiding.

Maintain adequate hydration up to 3,000 ml daily, unless

contraindicated. Scheduling fluid intake promotes regular bladder

distention and optimal time intervals between voidings. Limit fluid

intake to 150 ml after dinner to reduce need to void at night.

Assist with specific bladder elimination procedures, such as the

following: bladder training—this involves muscle-strengthening

183

exercises, adequate fluid intake, and carefully scheduled voiding

times (encourage voiding every 2 hr while awake and once during

night); rigid toilet regimen—place patient on toilet at specific inter-

vals (every 2 hr or after meals) and note whether voiding occurred

at each interval (this helps patient adapt to routine physiologic func-

tion); behavior modification—refrain from punishing unwanted

behavior (e.g., voiding in wrong place), and reinforce positive behav-

ior using social or material rewards (this helps patient learn alterna-

tives to maladaptive behaviors); use of external catheter—apply

according to established procedure and maintain patency, observe

condition of perineal skin and clean with soap and water at least

twice daily (this ensures effective therapy and prevents infection and

skin breakdown); application of protective pads and garments—use

only when interventions have failed to prevent infection and skin

breakdown and allow at least 4–6 weeks for trial period (establish-

ing continence requires prolonged effort).

Maintain continence based on patient’s voiding patterns and limita-

tions. Respond to call light promptly to avoid delays in voiding routine.

Orient patient to toileting environment: time, place, and activity

to offer security. Provide privacy and adequate time to void to allow

patient to void easily without anxiety.

Replace wet clothes immediately. Select clothing that promotes

easy dressing and undressing (e.g., Velcro fasteners and gowns) to

reduce patient’s frustration with voiding routine.

Inform: Teach family members and support personnel to reduce anxi-

ety that results from noninvolvement. Instruct patient and family

members on continence techniques to use at home to increase

chances of successful bladder retraining.

Attend: Encourage patient and family members to share feelings

related to incontinence. This allows specific problems to be identified

and resolved. Attentive listening conveys recognition and respect.

Manage: Refer patient/family to home healthcare agency, or support

group to provide access to additional community resources.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Prompted Voiding; Self-Care Assistance; Uri-

nary Elimination Management; Urinary Habit Training

References

Dowd, T., & Dowd, E. T. (2006, January–February). A cognitive therapy

approach to promote continence. Journal of Wound, Ostomy and
Continence Nursing, 33(1), 63–68.

Zarowitz, B. J., & Ouslander, J. G. (2006, September–October). Management

of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265–270.

Nursing diagnosis – READINESS FOR ENHANCED IMMUNIZATION STATUS

READINESS  FOR  ENHANCED

IMMUNIZATION  STATUS

DEFINITION

A pattern of conforming to local, national, and/or international stan-

dards of immunization to prevent infectious disease(s) that is sufficient

to protect a person, family, or community and can be strengthened

DEFINING CHARACTERISTICS

Expresses desire to enhance

• Behavior to prevent infectious disease.

• Identification of possible problems associated with immunizations.

• Identification of providers of immunizations.

• Immunization status.

• Knowledge of immunization standards.

• Record keeping of immunizations.

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Healthcare system

• Self-perception

EXPECTED OUTCOMES

The patient will

• Express knowledge of health-seeking behaviors necessary to partic-

ipate in immunization.

• Demonstrate adherence behavior to standard recommended immu-

nization protocols.

• Develop an ongoing plan for maintaining records of

immunizations.

SUGGESTED NOC OUTCOMES

Community Health Status: Immunity; Community Risk Control:

Communicable Disease; Immunization Behavior; Knowledge:

Infection

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s prior participation in immunization pro-

gram. Determine patient’s perception of the need for the prevention

of infectious diseases and responsibility for controlling the spread

of communicable disease. Assess patient’s attitude toward health-

seeking behavior that leads to immunization and knowledge of

infection control through immunization for communicable disease.

Assessment factors help in determining appropriate interventions.

Perform: Administer vaccines, as ordered, to ensure expected result

will occur. Implement a mechanism or device for record keeping

of immunizations to prevent gaps and overlaps in patient immuniza-

tions.

Inform: Help patient understand possible risks associated with immu-

nizations to assist patients identify reportable risks and

complications resulting from immunizations.

181

Attend: Encourage patients to have immunizations as close to due

dates as possible to ensure that protection from disease will be con-

sistent and continuous.

Listen attentively to what patient has to say about fear of vaccines.

Fear is often the factor that keeps people from being vaccinated.

Manage: Request for a case manager to make a home visit to help

prepare the family for the patient’s return to a safe environment.

Refer patient to community resources that may offer assistance to

the patient when needed.

Offer written information that can be referred to when needed.
Refer to home health nurse for a follow-up visit in the home.

SUGGESTED NIC INTERVENTIONS

Communicable Disease Management; Immunization/Vaccination

Management; Infection Control

Reference

Wiggs-Stayner, K. S., et al. (2006, August). The impact of mass school immu-

nization on school attendance. Journal of School Nursing, 22(4), 9–22.

Nursing diagnosis – DISTURBED PERSONAL IDENTITY

DISTURBED  PERSONAL  IDENTITY

DEFINITION

Inability to maintain an integrated and complete perception of self

DEFINING CHARACTERISTICS

• Disturbed body image

• Contradictory personal traits

• Fluctuating feelings about self

• Ineffective role performance

• Gender confusion

• Ineffective coping

• Unable to distinguish between

• Uncertainty about ideological

inner and outer stimuli

and cultural values

• Delusional description of self

• Uncertainty about goals

• Feelings of emptiness

• Disturbed relationships

• Feelings of strangeness

RELATED FACTORS

• Organic brain syndrome

• Situational crisis

• Dissociative identity disorder

• Dysfunctional family processes

• Psychiatric disorders

• Cultural discontinuity

• Low self-esteem

• Cult indoctrination

• Manic states

• Discrimination or prejudice

• Social role change

• Use of psychoactive drugs

• Stage of growth

• Ingestion of toxic chemicals

• States of development

• Inhalation of toxic chemicals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Safety

• Sexual practices

• Mental status

• Cultural beliefs

• Self-care

• Relationships

EXPECTED OUTCOMES

The patient will

• Contract for safety.

• Identify internal versus external stimuli.

• Maintain adequate nutritional intake.

• Identify personal goals and realistic steps toward those goals.

• Compile a list of resources to call when needed.

• Remain free from substance abuse.

• Secure a safe place to live in.

SUGGESTED NOC OUTCOMES

Coping; Distorted Thought; Impulse self-Control; Self-Control;

Self-Esteem

INTERVENTIONS AND RATIONALES

Determine:  Assess for suicidal/homocidal ideation, self-induced cuts

or burns. Assess for self-induced vomiting or restricting of food.

Thorough mental status examination. Individuals struggling with

identified issues are at an increased safety risk.

179
Monitor mental status daily to be able to intervene if necessary.
Monitor weight weekly to be able to detect changes that may

require further intervention.

Perform:  Contract with patient for safety. Schedule meetings with

patient to process feelings and experiences. Demonstrating care and

compassion for the patient allows him or her to feel safe and pro-

motes healing.

Inform:  Instruct patient to journal feelings and list coping strategies.

Journaling can help a patient maintain self-control and may increase

insight.

Attend:  Accept patient in his or her struggle. Reinforce taking

healthy risks and appropriate expression of feelings. Appropriate

expression of feelings enhances self-esteem and promotes resiliency.

Manage:  Refer patients to mental health services for medication and

symptom management. Disturbed personal identity may require

ongoing mental health care.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Environmental Management: Safety; Role

Enhancement; Self-Esteem Enhancement

Reference

Boyd, M. A. (2008). Psychiatric nursing. Philadelphia: Lippincott Williams &

Wilkins.

Nursing diagnosis – HYPOTHERMIA

HYPOTHERMIA

DEFINITION

Body temperature below normal range

DEFINING CHARACTERISTICS

• Body temperature below normal range

• Cool, pale skin

• Cyanotic nail beds

• Increased blood pressure, heart rate, and capillary refill time

• Piloerection

• Shivering

RELATED FACTORS

• Aging

• Exposure to cool environment

• Consumption of alcohol

• Illness

• Damage to hypothalamus

• Inactivity

• Decreased ability to shiver

• Inadequate clothing

• Decreased metabolic rate

• Malnutrition

• Evaporation from skin in cool

• Medications

environment

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Maintain body temperature within normal range.

• Have warm and dry skin.

• Maintain heart rate and blood pressure within normal range.

• Not shiver.

• Express feelings of comfort.

• Show no complications associated with hypothermia, such as soft-

tissue injury, fracture, dehydration, and hypovolemic shock, if
warmed too quickly.

• State an understanding of how to prevent further episodes of

hypothermia.

SUGGESTED NOC OUTCOMES

Neurological Status: Autonomic; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor body temperature at least every 4 hr or more

frequently, if indicated, to evaluate effectiveness of interventions.

Record temperature and route to allow accurate data comparison.

Baseline temperatures vary, depending on route used. If temperature

drops below 95   F (35   C), use a low-reading thermometer to obtain

accurate reading.

177
Monitor and record neurologic status at least every 4 hr. Falling

body temperature and metabolic rate reduce pulse rate and blood

pressure, which reduces blood perfusion to brain, resulting in disori-

entation, confusion, and unconsciousness.

Monitor and record heart rate and rhythm, blood pressure, and

respiratory rate at least every 4 hr. Blood pressure and pulse

decrease in hypothermia. During rewarming, patient may develop

hypovolemic shock. During warming, ventricular fibrillation and car-

diac arrest may occur, possibly signaled by irregular pulse.

Perform: Provide supportive measures, such as placing patient in

warm bed and covering with warm blankets, removing wet or con-

strictive clothing, and covering metal or plastic surfaces that contact

patient’s body. These measures protect patient from heat loss.

Follow prescribed treatment regimen for hypothermia: As ordered,

administer medications to prevent shivering to avoid overheating.

Monitor and record effectiveness. As ordered, administer analgesic

to relieve pain associated with warming. Monitor and record effec-

tiveness.

Use hyperthermia blanket to warm patient if temperature drops

below 95   F (35   C). Warm patient to 97   F (36.1   C).

As appropriate, administer fluids during rewarming to prevent

hypovolemic shock. If administering large volumes of intravenous

fluids, consider using a fluid warmer to avoid heat loss.

Inform: Discuss precipitating factors with patient, if indicated.

Patient may require community outreach assistance with certain pre-

cipitating factors, including inadequate living conditions, insufficient

finances, and abuse of medications (such as sedatives and alcohol).

Instruct patient in precautionary measures to avoid hypothermia,

such as dressing warmly even when indoors, eating proper diet, and

remaining as active as possible. Precautions help to prevent acciden-

tal hypothermia.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Comfort Level; Fluid Management; Hypothermia Treatment;

Temperature Regulation; Vital Signs Monitoring

Reference

Good, K. K., et al. (2006, May). Postoperative hypothermia—The chilling

consequences. AORN Journal, 83(5), 1055–1066.

Nursing diagnosis – HYPERTHERMIA

HYPERTHERMIA

DEFINITION

Body temperature elevated above normal range

DEFINING CHARACTERISTICS

• Fever

• Flushed, warm skin

• Increased heart and respiratory rate

• Seizures

RELATED FACTORS

• Anesthesia

• Increased metabolic rate

• Decreased perspiration

• Illness

• Dehydration

• Medications

• Exposure to hot environment

• Trauma

• Inappropriate clothing

• Vigorous activity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Remain afebrile.

• Maintain balance of intake and output within normal limits.

• Maintain urine specific gravity between 1.005 and 1.015.

• Exhibit moist mucous membranes.

• Exhibit good skin turgor.

• Remain alert and responsive.

SUGGESTED NOC OUTCOMES

Hydration; Infection Severity; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor heart rate and rhythm, blood pressure, respira-

tory rate, LOC and level of responsiveness, and capillary refill time

every 1–4 hr to evaluate effectiveness of interventions and monitor

for complications.

Determine patient’s preferences for oral fluids, and encourage

patient to drink as much as possible, unless contraindicated. Moni-

tor and record intake and output, and administer intravenous fluids,

if indicated. Because insensible fluid loss increases by 10% for every

1.8   F (1   C) increase in temperature, patient must increase fluid

intake to prevent dehydration.

Perform: Take temperature every 1–4 hr to obtain an accurate core

temperature. Identify route and record measurements.

Administer antipyretics as prescribed and record effectiveness.

Antipyretics act on hypothalamus to regulate temperature.

175
Use nonpharmacologic measures to reduce excessive fever, such as

removing sheets, blankets, and most clothing; placing ice bags on

axillae and groin; and sponging with tepid water. Explain these

measures to patient. Nonpharmacologic measures lower body tem-

perature and promote comfort. Sponging reduces body temperature

by increasing evaporation from skin. Tepid water is used because

cold water increases shivering, thereby increasing metabolic rate and

causing temperature to rise.

Use a hypothermia blanket if patient’s temperature rises above

103   F (39.4   C), if ordered. Monitor vital signs every 15 min for

1 hr and then as indicated. Prolonged hyperthermia may lead to

complications such as seizures. Turn off blanket if shivering occurs.

Shivering increases metabolic rate, increasing temperature.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Fever Treatment; Fluid Management;

Temperature Regulation

Reference

Kayser-Jones, J. (2006, June). Preventable causes of dehydration: Nursing

home residents are especially vulnerable. American Journal of Nursing,
106(6), 45.

Nursing diagnosis – HOPELESSNESS

HOPELESSNESS

DEFINITION

Subjective state in which an individual sees few or no available alter-

natives or personal choices available and is unable to mobilize energy

on own behalf

DEFINING CHARACTERISTICS

• Decreased appetite, affect, response to stimuli, verbalization

• Increased or decreased sleep

• Lack of involvement in self-care

• Nonverbal cues, such as closing eyes, shrugging in response to

question, and turning away from speaker

• Passivity and lack of initiative

RELATED FACTORS

• Abandonment

• Lost belief in spiritual power

• Deteriorating physical

• Lost belief in transcendent

condition

power

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Roles/responsibilities

• Coping

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Identify feelings of hopelessness regarding present situation.

• Demonstrate more effective communication skills.

• Resume appropriate rest and activity pattern.

• Participate in self-care activities and decisions regarding care planning.

• Use diversional activities.

SUGGESTED NOC OUTCOMES

Acceptance: Health Status; Adaptation to Physical Disability;

Depression Control; Hope; Quality of Life

INTERVENTIONS AND RATIONALES

Determine: Assess the following: nature of current medical diagnosis;

patient’s knowledge about medical diagnosis; actual or perceived

self-care deficits; mental status; communication patterns and support

systems; nutritional status and appetite; and sleep patterns. Also

monitor heart rate and blood pressure; respiratory rate, quality and

depth of respirations, and breath sounds. Assessment factors will

help identify appropriate interventions.

Perform: Follow medical regimen to manage the patient’s physiologic

condition. Build non–care-related time into the daily schedule to

allow time to develop a trusting relationship with the patient.

Provide comfort measures: adjust lighting and sound to minimize

irritating stimuli; offer back rubs and space procedures to promote

relaxation.

173

Inform: Keep patient informed about what to expect and when to

expect it. Accurate information reduces anxiety.

Teach self-healing techniques to both the patient and the family,

such as meditation, guided imagery, yoga, and prayer, to enhance

coping strategies. Teach patient how to incorporate the use of self-

healing techniques in carrying out usual daily activities.

Attend: Encourage patient to talk about personal assets and accom-

plishments and about improvements in his or her condition, no mat-

ter how small they may seem. Give positive feedback. Conversation

assists evaluation of patient’s self-concept and adaptive abilities.

Direct the patient’s focus beyond the present state. For example,

“Your nasogastric tube will come out tomorrow and you will feel

more comfortable.” This helps instill hope.

Encourage patient to talk about appropriate diversions and to

participate in them. Pleasurable activity decreases potential hazard

of crisis.

Manage: Refer patient and family to other professional caregivers,

for example, dietitian, social worker, clergy, mental health

professional, and support groups such as Ostomy Club, I Can Cope,

and Reach for Recovery. Assist patient to utilize appropriate

resources by contacting family and scheduling follow-up

appointments. These measures help give the patient a sense of direc-

tion and control over his or her future care.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Decision-Making Support; Energy

Management; Mutual Goal Setting; Sleep Enhancement; Spiritual

Growth Facilitation; Support Group

Reference

Kronenwetter, C., et al. (2005, March–April). A qualitative analysis of inter-

views of men with early stage prostate cancer. Cancer Nursing, 28(2),
99–107.

Nursing diagnosis – READINESS FOR ENHANCED HOPE

READINESS  FOR  ENHANCED  HOPE

DEFINITION

A pattern of expectations and desires that is sufficient for mobilizing

energy on one’s own behalf and can be strengthened

DEFINING CHARACTERISTICS

Expresses desire to enhance:

• Ability to set personal goals

• Belief in possibilities

• Congruency of expectations with desires

• Hope

• Interconnectedness with others

• Problem solving to meet goals

• Sense of meaning to life

• Spirituality

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Roles/responsibilities

• Coping

• Self-perception

• Emotional status

EXPECTED OUTCOMES

The patient will

• Express desire for positive health outcomes.

• Share personal goals to increase autonomy and personal

satisfaction.

• Increase quality of life.

• Plan to promote maximal physical, mental, social, and psychologi-

cal abilities.

• Share strategies to live a meaningful life.

• Express awareness of the need for developing and maintaining a

positive attitude of hope.

• Seek spiritual support as needed.

SUGGESTED NOC OUTCOMES

Hope; Personal Well-Being; Quality of Life; Will to Live

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s perception of ability to set personal goals.

Assess expression of desire to build on possibilities for the future,

and ability to align desires and expectations. Assess ability of patient

to maintain and enhance relationships with others. Assess patient’s

and family’s spiritual needs, including religious beliefs and affiliation.

Information from assessment will assist in determining appropriate

interventions.

Perform: Schedule time to meet with family and patient to listen to

ways in which they plan to enhance their coping skills in the present

situation.

171
Facilitate opportunities for spiritual nourishment and growth to

address patient’s holistic needs for maximal therapeutic environment.

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

such as meditation, guided imagery, yoga, and prayer, to promote

relaxation.

Teach patient how to incorporate the use of self-healing techniques

in carrying out usual daily activities. Practicing will increase the

chance that the patient will himself use these techniques.

Teach caregivers to assist patient with self-care activities in a way

that maximizes patient’s comfort. Comfort will reduce anxiety and

help patient cooperate with his or her treatment.

Demonstrate procedures and encourage participation in patient’s

care.

Provide patient with concise information about patient’s condition.

Be aware of what the family members have already been told.

Attend: Reinforce family’s efforts to care for the patient. Let them

know they are doing well to ease adaptation to new caregiver roles.

Encourage family to support patient’s independence.

Encourage patient’s cooperation as you continue with healing

techniques, such as therapeutic touch. Cooperation will enhance the

effect of the therapy.

Provide emotional support to family and be available to answer

questions. Being available to answer questions and listen builds trust

of the family.

Manage: Refer family to community resources and support groups to

assist in managing patient’s illness and providing emotional and

financial assistance to caregivers.

Refer to a member of the clergy or a spiritual counselor, accord-

ing to the patient’s preference, to show respect for the patient’s

beliefs and provide spiritual care.

SUGGESTED NIC INTERVENTIONS

Hope Facilitation; Self-Esteem Enhancement; Spiritual Growth Facili-

tation

Reference

Davidson, P. M., et al. (2007, January–February). Maintaining hope in transi-

tion: A theoretical framework to guide interventions for people with heart
failure. Journal of Cardiovascular Nursing, 22(1), 58–64.

Nursing diagnosis – IMPAIRED HOME MAINTENANCE

IMPAIRED  HOME  MAINTENANCE

DEFINITION

Inability to independently maintain a safe growth-promoting imme-

diate environment

DEFINING CHARACTERISTICS

• Difficulty in maintaining home in a comfortable environment

• Outstanding debts or financial crises

• Request for assistance with home maintenance

• Disorderly surroundings

• Unwashed or unavailable cooking equipment, clothes, or linens

• Accumulation of dirt, food wastes, or hygienic wastes

• Offensive odors

• Inappropriate household temperatures

• Lack of necessary equipment or aids

• Presence of vermin or rodents

RELATED FACTORS

• Deficient knowledge

• Impaired functioning

• Disease

• Insufficient finances

• Inadequate support systems

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Roles/relationships

• Coping

• Self-perception

• Knowledge

EXPECTED OUTCOMES

The patient and family members will

• Express concern about poor home maintenance.

• Verbalize plans to correct health and safety hazards in home.

• Identify community resources available to help maintain home.

SUGGESTED NOC OUTCOMES

Family Functioning: Role Performance; Self-Care: IADLs

INTERVENTIONS AND RATIONALES

Determine: Assess home environment, financial resources, patient’s

knowledge about self-care; and communication patterns in the fam-

ily. Assessment information will assist in identifying appropriate

interventions.

Perform: List obstacles to effective home maintenance management

with patient and family to develop understanding of potential and

actual health and safety hazards. Begin discussions at patient’s level

of comfort. Adult learners learn best where they have specific needs

to fulfill.

Assist family members to assign daily and weekly responsibility

for home maintenance activities. Having a schedule will promote

consistency in following the plan of care.

169

Inform: Teach patient and family the importance of home

maintenance to ensure safety. Provide written materials on environ-

mental aspects of home maintenance.

Teach skills such as setting down and choosing from a list of

options, and assertiveness skills to enhance coping strategies. Help

patient and family develop a program by using relaxation strategies

(i.e., meditation, guided imagery, yoga, exercise) to reduce anxiety.

Attend: Encourage weekly discussions about progress in maintaining

home maintenance schedule to develop family unity and allow mem-

bers to address problems before they become overwhelming.

Manage: Assist family members to contact community agencies that

can assist them in their efforts to improve home maintenance man-

agement, such as self-help groups, cleaning services, and extermina-

tors. Community resources can lessen family’s burden while

members learn to function independently.

SUGGESTED NIC INTERVENTIONS

Active Listening; Coping Enhancement; Counseling; Emotional

Support; Family Integrity Promotion; Family Support; Home

Maintenance Assistance

Reference

Horvath, K. J., et al. (2005, September–October). Caregiver competence to

prevent home injury to the care recipient with dementia. Rehabilitation
Nursing, 30(5), 189–196.

Nursing diagnosis – INEFFECTIVE HEALTH MAINTENANCE

INEFFECTIVE  HEALTH  MAINTENANCE

DEFINITION

Inability to identify, manage, and/or seek out help to maintain health

DEFINING CHARACTERISTICS

· Demonstrated lack of adaptive behaviors (internal or external

environmental changes)

· Demonstrated lack of knowledge regarding basic health practices

· History of lack of health-seeking behaviors

· Reported or observed impairment of personal support systems

· Reported or observed inability to take responsibility for meeting

basic health practices in any or all functional pattern areas.

· Reported or observed lack of equipment or financial and other

resources

RELATED FACTORS

· Cognitive impairment

· Diminished gross motor skills

· Complicated grieving

· Inability to make appropriate

· Deficient communication skills

judgments

· Diminished fine motor skills

· Ineffective family coping

ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Communication

· Knowledge

· Coping

· Risk management

· Healthcare system

· Values and beliefs

EXPECTED OUTCOMES

The patient will

· Maintain current health status.

· Sustain no harm or injury.

· Verbalize feelings and concerns.

· Explain health maintenance program.

· Identify available health resources.

SUGGESTED NOC OUTCOMES

Coping; Decision Making; Health Beliefs: Perceived Resources;

Health-Promoting Behavior; Social Support; Spiritual Health

INTERVENTIONS AND RATIONALES

Determine: Assess current health status; personal habits such as use

of tobacco, drugs, and alcohol; level of knowledge about disease

process; level of family and community assistance; coping

mechanisms and communication skills (verbal and written); and

degree of motivation to maintain health. Assessment factors will

assist the nurse in establishing interventions for this diagnosis.

Perform: Provide assistance with self-care, as needed. Encourage

increasing levels of independence. The patient should be as

independent in ADLs as possible.

167

Administer medications as prescribed to ensure continuation of

therapy.

Adapt environment to that which is best suited to the particular

patient. Reorient the patient as needed. In the disoriented patient,

reorientation should take place frequently to keep the person as

close to knowing person, place, and time as possible.

Provide a consistent caretaker whenever possible to promote sta-

bility for the patient.

Plan a health maintenance program for patient and family members

addressing current disabilities. Provide patient and family with a writ-

ten copy. Giving instructions in writing will reinforce the various

aspects of the program and increase the possibility of compliance.

Inform: Fully describe all aspects of the patient’s care to the family

to elicit cooperation from them in continuing a plan.

Instruct family members how to carry out health maintenance

practices. Demonstrate skills such as bathing, feeding, and reality

orientation; then, have family members return demonstration under

supervision. Involving family members allows them the opportunity

to perform skills and solve problems with support and supervision.

Provide specific instructions on how to maintain a safe

environment for the patient to avoid falls and other types of

accidental injuries.

Teach relaxation techniques (e.g., guided imagery, progressive mus-

cle relaxation, and meditation) that can be done by the patient and

the family to enhance coping ability and restore psychological and

physical equilibrium by decreasing autonomic response to anxiety.

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

cerns related to health maintenance. This promotes better

understanding and greater ease in managing challenging situations.

Demonstrate willingness to repeat instruction and demonstrate

skills needed to care for the patients until they feel comfortable.

Manage: Refer to social and community resources, such a stroke sup-

port group, and Alzheimer’s family support group. This helps the family

gain support and receive factual information. It provides opportunity to

express feeling in a group where others are experiencing similar issues.

Making referrals is appropriate to mental health professional to

assist with prevention of burnout for the family.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Coping Enhancement; Counseling; Discharge

Planning; Health Education; Health System Guidance; Physician

Support; Referral; Support System Enhancement

Reference

Cole, C. S., et al. (2006, April). Assessment and discharge planning for the

older hospitalized adults with delirium. Medsurg Nursing, 15(2), 71–76.

Nursing diagnosis – RISK FOR DISPROPORTIONATE GROWTH

RISK  FOR  DISPROPORTIONATE  GROWTH

DEFINITION

At risk for growth above the 97th percentile or below the 3rd per-

centile for age, crossing the percentile channels

RISK FACTORS

· Altered nutritional status

· Inability to digest and absorb

· Any disease that persists over

nutrients

time, especially during critical

periods of development

· Neuroendocrine factors, such

as altered levels of growth or

· Environmental hazards, such

thyroid hormones

as chemical or radiation expo-

sure, lead exposure, passive

inhalation of tobacco smoke,

and exposure to air, water, or

food contaminants

· Prenatal influences, such as

maternal exposure to drugs or

alcohol, severe maternal malnu-

trition, and maternal smoking

· Financial or socioeconomic

· Genetic abnormalities

hardships

ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Nutrition

· Sleep

· Activity

· Coping

EXPECTED OUTCOMES

The child will

· Grow and gain weight as expected on the basis of growth-chart

norms for age and gender.

· Consume _____ calories and ___ml of fluids representing ____

servings (specify for each food group).

· Achieve ____ hours of uninterrupted sleep daily.

· Maintain age-appropriate activity level.

Parents will

· Identify risk factors that may lead to disproportionate growth.

· State understanding of preventive measures to reduce risk of dis-

proportionate growth.

SUGGESTED NOC OUTCOMES

Appetite; Body Image; Child Development: Middle Childhood

Growth; Risk Control; Weight: Body Mass

INTERVENTIONS AND RATIONALES

Determine: Monitor weight and height weekly to evaluate progress.

Monitor temperature, activity levels, sleep patterns, and changes

in nutritional status. Monitor prescribed and over-the-counter med-

ications taken. Determine exposure to tobacco smoke and/or other

environmental contaminants. These assessment parameters will assist

in developing appropriate interventions.

Perform: Weigh and measure the child weekly to evaluate progress.

Review growth-chart curve to compare with growth history.

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Establish meal program that meets the child’s nutritional needs.

Establish routine sleep schedule for the child. Help child keep a

chart to encourage increased levels of self-care.

List age-appropriate activities and exercises for the child to stimu-

late bone and muscle development and promote cardiovascular health.

Administer prescribed drugs and treatments as ordered. Ensure

that the child and parents understand the intended action and side

effects that may occur to ensure that therapy can continue without

interruption.

Provide an environment that is conducive to promote changes the

child must make. Environment can be a powerful motivator.

Inform: Educate child and parents on nutritional requirements for

child’s age and gender. Discuss meals available to the child at home

to promote growth.

Teach child and parents about risk factors associated with dispro-

portionate growth, such as poor nutrition, lack of regular sleep,

environmental hazards, or lack of age-appropriate activities. Help to

identify preventive measures to be taken in the home to promote

continuity of care.

Attend: Encourage healthy, loving interactions between child and

other family members. Demonstrate healthy and positive interactions

with the child. Disproportionate growth may be associated with

emotional deprivation.

Encourage child and parents to express feelings about present

state of child’s health. Listen attentively with understanding about

the self-esteem associated with what is considered by peers to be

other than normal. Parents will need help in supporting the child

through difficulties coping with normal peers.

Manage: If a medical or psychiatric illness places child at risk for dis-

proportionate growth, make sure child gets adequate follow-up med-

ical care and ensure that the care is appropriate and professional.

This will ensure the child’s right to receive remedial and educational

care in accordance with his disability, as guaranteed by federal law.

If financial hardship interferes with the family’s ability to provide

for child with disproportionate growth, offer a referral to a social

worker to improve the family’s access to community resources.

SUGGESTED NIC INTERVENTIONS

Active Listening; Behavior Modification; Coping Enhancement;

Counseling; Nutritional Management; Patient Contracting; Weight

Management

Reference

Gregory, K. (2005, January–February). Update on nutrition for pre-term and

full term infants. Journal of Obstetric, Gynecology, and Neonatal Nursing,

34(1), 98–108.

Nursing diagnosis – DELAYED GROWTH AND DEVELOPMENT

DELAYED  GROWTH  AND  DEVELOPMENT

DEFINITION

Deviations from age-group norms

DEFINING CHARACTERISTICS

• Altered physical growth

• Delay or difficulty in performing motor, social, or expressive skills

typical of age group

• Flat affect

• Listlessness and decreased response

• Inability to perform self-care activities or maintain self-control at

age-appropriate level

RELATED FACTORS

• Effect of physical disability

• Multiple caretakers

• Environmental deficiencies

• Prescribed dependence

• Inadequate caretaking

• Separation from significant

• Inconsistent responsiveness

others

• Indifference

• Stimulation deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Family roles and responsibilities

• Cardiac function

• Nutrition

• Communication

• Sleep

EXPECTED OUTCOMES

The child will

• Demonstrate skills appropriate for age.

• Participate in developmental stimulation program to increase skill

levels.

The parents will

• Express understanding of norms for growth and development.

• Use community resources to promote child’s development.

• Provide play activities to promote child’s development.

SUGGESTED NOC OUTCOMES

Child Development: Middle Childhood; Growth; Physical

Maturation: Female; Physical Maturation: Male

INTERVENTIONS AND RATIONALES

Determine: Monitor weight and height weekly. Monitor nutritional

intake, activity level, and sleep patterns. Documentation of these

factors will help measure progress over time.

Assess cardiac functioning and respiratory status to ensure that

child is healthy enough to participate in activities.

Assess child’s motor skills, communication patterns, social skills, and

cognitive abilities to evaluate where skill development may be needed.

Assess support systems available to child and parents. Where there

are gaps, other sources of support may need to be put in place.

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Perform: Establish a meal program to promote nutritional needs.

Weigh and measure child weekly and review growth-chart curve to

monitor progress.

Establish a routine sleep schedule for child to ensure that the

child is healthy enough to participate in an activity.

List age-appropriate activities and exercises to stimulate bone and

muscle development and promote cardiovascular health. Provide

appropriate play activities, such as building blocks, dolls, crayons,

or games to promote development.

Administer prescribed drugs and treatments as ordered. Ensure

parents and child understand intended action and possible side effects

to ensure therapy will continue as planned.

Provide an environment that is conducive to promote changes the

child must make. Environment can be a powerful motivator.

Inform: Provide parents with information about the causes of

delayed growth and development. Provide written information to

help them know what they can expect as a result of treatment.

Discuss age appropriate nutritional requirements with parents and

child and teach additional risk factors associated with delayed

growth (e.g., lack of regular sleep, environmental hazards). Teach

appropriate activities and encourage frequent play with child. These

measures promote continuity of care.

Attend: Five child positive reinforcement for demonstrating appropri-

ate skills and behavior and encourage parents to do the same to

encourage the child to continue developing skills.

Encourage child and parents to express feelings about present

state of child’s health. Listen attentively with understanding about

the self-esteem associated with what is considered by peers to be

other than normal. Parents need to be encouraged first to accept the

child as he is and then encourage the child to develop new skills

Development can occur only when parents and staff are both realis-

tic about the child’s present stage of development.

Manage: Provide parents with referrals to appropriate community

resources, including sources for financial assistance, child care, and

suppliers of adaptive equipment, to ensure the child’s right to receive

remedial and educational support in accordance with the disability,

as guaranteed by federal law.

SUGGESTED NIC INTERVENTIONS

Developmental Enhancement: Child; Health Screening; Nutrition

Management; Risk Identification; Self-Responsibility Facilitation

Reference

Wagner, J., et al. (2006, September–October). Nurses’ utilization of parent

questionnaires for developmental screening. Pediatric Nursing, 32(5),
409–412.

Nursing diagnosis – RISK FOR COMPLICATED GRIEVING

RISK  FOR  COMPLICATED  GRIEVING

DEFINITION

At risk for a disorder that occurs after the death of a significant other,

in which the experience of distress accompanying bereavement fails to

follow normative expectations and manifests in functional impairment

RISK FACTORS

• Death of a significant other

• Emotional instability

• Lack of social support

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Roles/relationships

• Emotional status

• Sleep/rest

• Nutrition status

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Express appropriate feelings of loss, guilt, fear, anger, or sadness.

• Identify loss and describe meaning of loss.

• Appropriately move through stages of grieving.

• Maintain healthy patterns of sleep, activity, and eating.

• List personal strengths.

• Use healthy coping mechanisms and social support systems.

• Seek fulfillment through preferred spiritual practices.

• Begin planning for future.

SUGGESTED NOC OUTCOMES

Grief Resolution; Life Change Adjustment

INTERVENTIONS AND RATIONALES

Determine: Identify areas of hope in patient’s life to help decrease

anger and feelings of frustration.

Identify previous losses and assess for depression to establish a

baseline.

Perform: Perform interventions to promote sleep such as giving

snack, pillows, backrub, or shower to enhance rest.

Inform: Teach patient relaxation techniques such as guided imagery,

meditation, or progressive muscle relaxation to promote feelings of

comfort.

Attend: Encourage patient to express grief and feelings of anger,

guilt, and sadness. Inability to express these feelings may result in

maladaptive behaviors.

Encourage patient to express feelings in a way he is most comfort-

able with, for example, crying, talking, writing, and/or drawing.

Dysfunctional grieving may result from an inability to express

feelings freely.

161
Encourage patient to keep a journal to express feelings of grief

and loss. The act of writing about feelings may aid in grieving

process. Help patient form goals for the future to place the loss in

perspective and to move on to new situations and relationships.

Manage: Refer patient to community support systems to assist with

grieving process. Contact patient’s preferred spiritual leader if

patient desires. This may provide relief from spiritual distress.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Counseling; Emotional Support; Family Ther-

apy; Grief Facilitation Work

Reference

Pilkington, F. B. (2008, January). Expanding nursing perspectives on loss and

grieving. Nursing Science Quarterly, 21(1), 6–7.

Nursing diagnosis – COMPLICATED GRIEVING

COMPLICATED  GRIEVING

DEFINITION

A disorder that occurs after the death of a significant other, in which

the experience of distress accompanying bereavement fails to follow

normative expectations and manifests in functional impairment

DEFINING CHARACTERISTICS

• Decreased functioning in life roles

• Decreased sense of well-being

• Depression

• Fatigue

• Grief avoidance

• Longing for the deceased

• Low levels of intimacy

• Persistent emotional distress

• Preoccupation with thoughts of the deceased

• Rumination

• Searching for the deceased

• Verbalization of anxiety; distress about the deceased; detachment

from others; self-blame; disbelief, mistrust, failure to accept the
death; feeling dazed, empty, in shock, or stunned; persistent
painful memories

RELATED FACTORS

• Death of a significant other

• Lack of social support

• Emotional instability

• Sudden death of significant other

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Emotional

• Sleep/rest

• Values/beliefs

• Nutrition

• Roles/relationships

EXPECTED OUTCOMES

The patient will

• Express appropriate feelings of loss, guilt, fear, anger, or sadness.

• Identify the loss and describe what it means to him.

• Appropriately move through stages of grief.

• Maintain healthy patterns of sleep, activity, and eating.

• Verbalize understanding that grief is normal.

• Use healthy coping mechanisms and social support systems.

• Seek fulfillment through preferred spiritual practices.

• Begin planning for future.

SUGGESTED NOC OUTCOMES

Grief Resolution; Life Change; Psychosocial Adjustment

INTERVENTIONS AND RATIONALES

Determine: Identify previous losses and assess for depression. Older

patients may experience losses frequently and without adequate

159

recovery time before the next loss. Multiple losses contribute to

depression.

Perform: Help patient identify an area of hope in his or her life.

Focusing on a life purpose may decrease anger and feelings of frus-

tration.

Help patient focus realistically on changes the loss has brought

about. This will assist patient in forming plans for the future and

improving social relationships.

Help patient formulate goals for the future to place loss in

perspective and move on to new situations and relationships.

Attend: Encourage patient to express grief and feelings of anger,

guilt, and sadness. Inability to express these feelings may result in

maladaptive behaviors.

Encourage journaling to express grief and loss. Writing and

exploring feelings is an active process, which may assist in grieving.

Encourage patient and family to engage in reminiscing to give

purpose and meaning to the loss and assist in maintenance of self-

esteem.

Manage: Contact patient’s preferred spiritual leader, if patient

desires, to provide relief from spiritual distress.

Refer patient to community support systems to help him deal with

his bereavement and grief process.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Counseling; Emotional Support; Family Ther-

apy; Grief Facilitation Work

Reference

Szanto, K., et al. (2006, February). Indirect self-destructive behavior and overt

suicidality in patients with complicated grief. Journal of Clinical Psychiatry,
67(2), 233–239.