Nursing diagnosis – GRIEVING

GRIEVING

DEFINITION

A normal complex process that includes emotional, physical, spiri-

tual, social, and intellectual responses and behaviors by which indi-

viduals, families, and communities incorporate an actual,

anticipated, or perceived loss into their daily lives

DEFINING CHARACTERISTICS

• Altered communication patterns

• Change in eating, sleep and dream patterns, activity level, or libido

• Denial of potential loss of life

• Difficulty taking on different roles

• Expressed guilt, anger, sorrow, and bargaining

• Expressions of distress over potential loss of life

RELATED FACTORS

• Anticipatory loss of significant object or other

• Death of a significant other

• Loss of significant object (e.g., possession, job, status)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Growth and Development

• Roles/relationships

• Risk management

• Behavior

• Emotional

• Communication

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Express and accept feelings about anticipated death.

• Progress through stages of grieving process in his or her own way.

• Practice religious rituals and use other coping mechanisms appro-

priate to end of life.

• Have participation of family members or significant other in pro-

viding supportive care and comfort to patient.

SUGGESTED NOC OUTCOMES

Coping; Family Coping; Grief Resolution; Psychosocial Adjustment:

Life Change

INTERVENTIONS AND RATIONALES

Determine: Assess stage of grieving to establish a baseline.

Perform: Demonstrate acceptance of patient’s response to his or her

anticipated death, whatever that response may be: crying, sadness,

anger, fear, or denial. Each patient responds to dying in his or her

own way. Helping patient express feelings freely will enhance ability

to cope.

Help patient progress through psychological stages associated with

anticipated death, including shock and denial, anger, bargaining,

depression, and acceptance, to help you anticipate the dying

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patient’s psychological needs. Keep in mind, however, that not all

dying patients go through each stage.

Provide time for patient to express his or her feelings about death

or terminal illness. Active listening helps the patient lessen feelings

of loneliness and isolation. Refrain from approaching patient with a

busy, hurried attitude, which can block communication.

Establish a relationship that encourages patient to express

concerns about death. Basic nursing care combined with genuine

interest in the patient fosters trust and understanding.

Guide patient in life review. Encourage patient to write or tape-

record his or her life history as a lasting gift to family members.

Life review allows patient to survey events from his or her past and

give them meaningful interpretation.

Inform: Inform patient about hospice services that emphasize symp-

tomatic relief and caring, with the aim of improving patient and

family comfort until death occurs, instead of prolonging life for its

own sake. Hospice care is an appropriate alternative for a patient

with an incurable illness.

Attend: Encourage family members to become involved in the care

of the dying patient. Communicate with patient and family members

honestly and compassionately. Giving family members a role in

patient care helps relieve anxiety and lessen feelings of regret and

guilt. Honest communication is important because family members

need an opportunity to acknowledge their loss and say farewell.

Support patient’s spiritual coping behaviors. For example, arrange

for patient to have objects that provide spiritual comfort (such as a

copy of Bible, prayer shawl, pictures, statues, or rosary beads) at the

bedside. Even patients for whom religious practice hasn’t been a

dominant part of life may turn to religion when confronted by

death or serious illness.

Manage: Involve an interdisciplinary team (including a psychologist,

nurse, the patient, a nutritionist, physician, physical therapist, and

chaplain) in providing care for a dying patient. Each team member

offers unique expertise for meeting the dying patient’s needs.

Provide referrals for home healthcare assistance if the patient will be

cared for at home to support the patient’s decision to remain at home.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Coping Enhancement; Family Support; Grief

Work Facilitation

Reference

Zimmerman, C., & Wennberg, R. (2006, August–September). Integrating pal-

liative care: A postmodern perspective. The American Journal of Hospice
and Palliative Care, 23(4), 255–258.

Nursing diagnosis – RISK FOR UNSTABLE BLOOD GLUCOSE

RISK  FOR  UNSTABLE  BLOOD  GLUCOSE

DEFINITION

At risk for variation of blood glucose/sugar levels from the normal

range

RISK FACTORS

• Deficient knowledge of

• Lack of adherence to diabetes

diabetes management

management

• Developmental level

• Physical activity level

• Dietary intake

• Physical/mental health status

• Inadequate blood glucose

• Pregnancy

monitoring

• Stress

• Lack of acceptance of diagnosis

• Weight gain or loss

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Neurocognition

• Emotional

• Nutrition

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Be free from symptoms of hypoglycemia/hyperglycemia.

• Have serum glucose to the prescribed desired range.

• Verbalize understanding of how to control blood glucose level.

SUGGESTED NOC OUTCOMES

Blood Glucose Level; Diabetes Self-Management; Knowledge:

Diabetes Management, Weight Control

INTERVENTIONS AND RATIONALES

Determine: Assess patient for symptoms of low serum glucose level

and maintain a patient airway if indicated. A low serum glucose

may not be detected in some patients until moderate to severe cen-

tral nervous system impairment occurs, which can lead to a compro-

mised airway and cardiac arrest.

Assess for the underlying cause (e.g., inadequate dietary intake;

illness such as nausea, vomiting, or diarrhea; and too much insulin)

to help patient prevent future episodes and adapt treatment strate-

gies and lifestyle changes.

Monitor or instruct patient to monitor glucose levels with a glu-

cometer at regular intervals to identify and respond early to fluctua-

tions in glucose levels that occur outside normal parameters.

Assess family understanding of prescribed treatment regimen. The

family plays an important role in supporting the patient.

Assess patient’s knowledge of hypo/hyperglycemia to ensure ade-

quate management and prevent future episodes.

Monitor for signs and symptoms of hyperglycemia (polyuria, poly-

dipsia, polyphagia, lethargy, malaise, blurred vision, and headache).

Early detection ensures prompt intervention and management.

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Assess for the underlying cause of elevated serum glucose level,

including inadequate dietary intake, illness, and poor medication

management to prevent future episodes and develope treatment

strategies such as changes in lifestyle.

Perform: Perform immediate finger stick with a glucometer to deter-

mine glucose level, which will guide treatment strategies. Administer

insulin, as prescribed, to treat elevated blood glucose levels.

Provide patient with glucose tablets or gel if he or she is

conscious and has ability to swallow. Administer intravenous glucose

if patient is unconscious or cannot swallow. Immediate treatment in

the form of oral or intravenous glucose must be administered to

reverse the low serum glucose level. If patient becomes nauseated,

turn patient on side to prevent aspiration.

Protect patient from injuries, such as falls. Symptoms of low

serum glucose place patient at risk for injury especially when driving

and performing other potentially dangerous activities.

Evaluate serum electrolyte levels. Administer potassium, as

prescribed. With elevated blood glucose levels, potassium and

sodium levels may be low, normal, or high, depending on the

amount of water loss. Consider performing serum testing for

HgbA1c (glycosylated hemoglobin A3C level) to evaluate average

blood glucose levels over a period of approximately 2–3 months and

to assess the adherence and effectiveness of the treatment regimen.

Inform: Teach patient and family self-management of hypoglycemia

and hyperglycemia including glucose monitoring at regular intervals

to treat abnormal glucose levels early and medication management,

nutritional intake, exercise, and regular follow-up visits with the

physician to ensure adequate understanding and management of the

treatment regimen to prevent future hyperglycemic events. Patient

and family teaching may include referrals to a diabetic educator, dia-

betic education classes, and a dietician.

Manage: Consult physician if signs and symptoms persist. Changes

in prescribed medications may be needed, such as with oral

hypoglycemic agents or insulin dosing. Call for emergency medical

services if patient is unstable outside the hospital.

SUGGESTED NIC INTERVENTIONS

Bedside Laboratory Testing; Health Education; Health Screening;

Nutritional Counseling; Teaching: Disease Process; Teaching:

Prescribed Medications

Reference

Oldroyd, J., et al. (2006). Randomized controlled trial evaluating lifestyle

interventions in people with impaired glucose tolerance. Diabetes Research
and Clinical Practice, 72(2), 117–127.

Nursing diagnosis – RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

RISK  FOR  DYSFUNCTIONAL

GASTROINTESTINAL  MOTILITY

DEFINITION

Risk for increased, decreased, ineffective, or lack of peristaltic activity

within the gastrointestinal system

RISK FACTORS

• Abdominal surgery

• Gastroesophageal reflux

• Diabetes

disease (GERD)

• Prematurity

• Unsanitary food preparation

• Decreased gastrointestinal

• Anxiety

circulation

• Lifestyle

• Pharmaceutical agents (e.g.,

• Immobility

narcotics, antibiotics, proton
pump inhibitors, and laxatives)

• Food intolerance (e.g., gluten,
lactose)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Fluid and electrolytes

• Elimination

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain adequate fluid and electrolyte balance.

• Identify diet selections and lifestyle changes that would promote

healthy GI function.

• Not experience altered GI motility related to prescribed

medications.

• Recognize chronic conditions that may contribute to altered GI

motility, for example, diabetes, GERD.

SUGGESTED NOC OUTCOMES

Electrolyte and Acid–Base Balance; Fluid Balance; Bowel Elimination

INTERVENTIONS AND RATIONALES

Determine: Assess patient for signs of fluid or electrolyte imbalance

related to increased or decreased GI motility. Fluid and electrolyte

alterations can result from either increased or decreased

gastrointestinal motility.

Assess patient for positive risk factors for altered GI motility. This

will allow for timely interventions to prevent complications associ-

ated with GI dysfunction.

Perform: Assist patients taking prescribed medications that affect

motility with strategies to avoid GI complications. Awareness of pre-

ventive measures will decrease GI complications.

Encourage early ambulation for postoperative patients receiving

opioids for pain control. Early ambulation will reduce the risk of

narcotic-related constipation.

Inform: Educate patient regarding the risk factors related to altered

GI motility, including certain food choices, fluid intake, medications,

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and activity. Promotion of healthy lifestyle choices will contribute to

positive patient outcomes.

Attend: Provide encouragement and support for behaviors that

enhance gastrointestinal health. Positive reinforcement results in

improved confidence in self-management of health behaviors.

Manage: Coordinate care with other disciplines as needed to

reinforce positive behaviors or to assist with complex situations.

SUGGESTED NIC INTERVENTIONS

Diarrhea Management; Electrolyte Monitoring; Fluid Management;

Nutrition Management

Reference

Mazumdar, A., Mishra, S., Bhatnagar, S., & Gupta, D. (2008). Intravenous

morphine can avoid distressing constipation associated with oral morphine:
A retrospective analysis of our experience in 11 patients in the palliative
care in-patient unit. The American Journal of Hospice & Palliative Care,
25, 282–284.

Nursing diagnosis – DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

DYSFUNCTIONAL  GASTROINTESTINAL

MOTILITY

DEFINITION

Increased, decreased, ineffective, or lack of peristaltic activity within

the gastrointestinal system

DEFINING CHARACTERISTICS

• Nausea

• Abdominal pain

• Vomiting

• Absence of flatus

• Abdominal distension

• Hard, dry stool

• Change in bowel sounds

• Difficulty passing stool

(e.g., absent, hypoactive,
hyperactive)

• Diarrhea
• Abdominal cramping

• Increased gastric residual

• Accelerated gastric emptying

RELATED FACTORS

• Anxiety

• Malnutrition

• Surgery

• Food intolerance (e.g., lactose,

• Immobility

gluten)

• Pharmacological agents (e.g.,

• Ingestion of contaminants

narcotics, laxatives, antibiotics,
anesthesia)

(e.g., food, water)
• Enteral feedings

• Aging

• Inactive lifestyle

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Verbalize strategies to promote healthy bowel function.

• Acknowledge the importance of seeking medical help for persistent

alteration in GI motility.

• Not experience any fluid and electrolyte imbalance as a result of

altered motility.

• Understand the need for early ambulation following abdominal

surgery.

SUGGESTED NOC OUTCOMES

Bowel Elimination, Electrolyte and Acid–Base Balance, Gastrointesti-

nal Function

INTERVENTIONS AND RATIONALES

Determine: Assess abdomen including auscultation in all four quad-

rants noting character and frequency to determine increased or

decreased motility.

Assess current manifestations of altered GI motility to help iden-

tify the cause of the alteration and guide development of nursing

interventions.

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Monitor intake and output to identify need for restoration of fluid

balance.

Perform: Collect and evaluate laboratory electrolyte specimens. Some

altered motility states may require electrolyte replacement therapy.

Insert nasogastric tube as prescribed for patients with absent

bowel sounds to relieve the pressures caused by accumulation of air

and fluid.

Inform: Educate patients regarding importance of maintaining diet

high in natural fiber and adequate fluid intake. Fiber increases stool

bulk and softens the stool. Fluid will promote normal bowel elimi-

nation pattern.

Attend: Encourage activities such as walking as tolerated for patients

with decreased GI motility. Increased activity will stimulate peristal-

sis and facilitate elimination.

Manage: Coordinate with dietitian and other healthcare professionals

as needed to meet the unique needs of each individual patient.

SUGGESTED NIC INTERVENTIONS

Fluid/Electrolyte Management; Gastrointestinal Intubation; Tube

Care: Gastrointestinal

Reference

Sabol, V. K., & Carlson, K. K. (2007). Diarrhea: Applying research to bedside

practice. AACN Advanced Critical Care, 18, 32–44.

Nursing diagnosis – IMPAIRED GAS EXCHANGE

IMPAIRED  GAS  EXCHANGE

DEFINITION

Excess or deficit in oxygenation and/or carbon dioxide elimination

at the alveolar-capillary membrane

DEFINING CHARACTERISTICS

• Abnormal pH and arterial

• Headache upon awakening

blood gases levels

• Hypoxia and hypoxemia

• Abnormal respiratory rate,

• Increased or decreased carbon

rhythm, and depth

dioxide levels

• Confusion

• Irritability/Restlessness

• Cyanosis

• Nasal flaring

• Diaphoresis

• Pale, dusky skin

• Dyspnea

• Tachycardia

RELATED FACTORS

• Alveolar-capillary membrane changes

• Ventilation–perfusion changes

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function

EXPECTED OUTCOMES

The patient will

• Carry out ADLs without weakness or fatigue.

• Maintain normal Hb and HCT levels.

• Express feelings of comfort in maintaining air exchange.

• Cough effectively and expectorate sputum.

• Be free from adventitious breath sounds.

• Perform relaxation techniques every 4 hr.

• Use correct bronchial hygiene.

SUGGESTED NOC OUTCOMES

Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital

Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor respiratory status; rate and depth of breaths;

chest expansion; accessory muscle use; cough and amount and color

of sputum; and auscultation of breath sounds every 4 hr to detect

early signs of respiratory failure.

Monitor vital signs, arterial blood gases, and Hb levels to detect

changes in gas exchange.

Report signs of fluid overload or dehydration immediately. This

can lead to changes in acid-base balance and affect respiratory status.

Perform: Elevate head 30 to facilitate lung expansion and prevent

atalectasis. Assist with ADLs as needed to decrease tissue oxygen.

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Perform bronchial hygiene as ordered (e.g., coughing, percussing,

postural drainage, and suctioning) to promote drainage and keep

airways clear. Administer bronchodilators, antibiotics, and steroids,

as ordered.

Record intake and output every 8 hr to monitor fluid balance.
Auscultate lungs every 4 hr and report abnormalities to detect

decreased or adventitious breath sounds.

Orient patient to the environment, that is, use of call bell, side

rails, and bed positioning controls. Place side rails up and bed

position down when the patient is in bed. Place personal items

within the patient’s reach. Assist patient when he or she is getting

out of bed in case of dizziness. These measures prevent risk of

falling. Move patient slowly to avoid hypostatic hypotension. Post

a notice where it can be seen that the patient is at risk for falling.

Inform: Teach and demonstrate correct breathing and coughing tech-

niques such as diaphragmatic or abdominal breathing and have

patient return demonstration to ensure patient understands proper

technique and promote effective coughing and deep breathing.

Teach patient correct way of using inhalers. Remind patient about

mouth care after each dose. Failure to clean the mouth after inhal-

ing can cause candidiasis in the throat.

Review all medications with patient and family and list side

effects for each to ensure that the patient recognizes side effects and

reports them to the physician.

Encourage relaxation techniques to reduce oxygen demand.

Attend: Encourage patient to express feelings. Attentive listening

helps build a trusting relationship.

Encourage family members to stay with the patient, especially

during times of anxiety to promote relaxation which reduces oxygen

demand.

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

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

Refer patient to community resources and offer written informa-

tion that can be referred to when needed.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Airway Management; Airway suctioning;

Anxiety Reduction; Energy Management; Exercise Promotion; Fluid

Management

Reference

Marklew, A. (2006, January–February). Body positioning and its effect on

oxygenation—A literature review. Nursing in Critical Care, 11(1), 16–22.

Nursing diagnosis – RISK FOR IMBALANCED FLUID VOLUME

RISK  FOR  IMBALANCED  FLUID  VOLUME

DEFINITION

At risk for a decrease, increase, or rapid shift from one to the other

of intravascular, interstitial, and/or intracellular fluid. This refers to

body fluid loss, gain, or both

RISK FACTORS

• Receiving apheresis

• Intestinal obstruction

• Abdominal surgery

• Sepsis

• Traumatic injury

• Pancreatitis

• Burns

• Ascites

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Remain hemodynamically stable.

• Not experience electrolyte imbalance.

• Maintain adequate urine output.

• Identify risk factors contributing to possible imbalanced fluid volume.

SUGGESTED NOC OUTCOMES

Fluid Balance; Hydration; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Assess for conditions that may contribute to imbalanced

fluid volume. Prompt treatment of the underlying cause may prevent

serious complications of fluid imbalance.

Monitor vital signs and other assessment parameters frequently.

Changes in heart rate and rhythm, blood pressure, and breath

sounds may indicate altered fluid status.

Monitor intake and output to evaluate need for fluid replacement.

Perform: Collect and evaluate urine output frequently. Measure urine

specific gravity as indicated. Decreased urine volume and elevated

specific gravity indicate hypovolemia.

Collect and evaluate serum electrolyte levels. Fluid alterations may

affect electrolyte levels.

Administer intravenous fluids as indicated. Proactive fluid manage-

ment may prevent serious imbalances.

Inform: Educate patient and family regarding fluid restrictions or

need for increased fluids, depending on underlying condition. Knowl-

edge will enhance feeling of participation and sense of control.

Attend: Provide encouragement and support for cooperation with

prescribed treatment regimen. Positive reinforcement will promote

compliance.

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Manage: Coordinate care with other members of healthcare team to

effectively manage underlying medical condition and prevent any

alteration in fluid balance.

SUGGESTED NIC INTERVENTIONS

Fluid Management; Fluid Monitoring; Intravenous Therapy

Reference

Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled

water. Journal of Perianesthesia Nursing, 23, 267–272.

Nursing diagnosis – RISK FOR DEFICIENT FLUID VOLUME

RISK  FOR  DEFICIENT  FLUID  VOLUME

DEFINITION

At risk for experiencing vascular, cellular, or intracellular

dehydration

RISK FACTORS

• Conditions  that  influence  fluid

• Knowledge deficit related to

needs (e.g., hypermetabolic state)

fluid volume

• Excessive loss of fluid from

• Loss of fluid through abnor-

normal routes (e.g., diarrhea)

mal routes (e.g., drainage

• Extremes of age or weight

tube)

• Factors that affect intake or

• Medications that cause fluid

absorption of, or access to,
fluids (e.g., immobility)

loss

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Maintain urine output of at least ___ ml/hr.

• Maintain electrolyte values within normal range.

• Maintain intake at _____ ml/24 hr.

• Have an intake equal to or exceeding output.

• Express understanding of need to maintain adequate fluid intake.

• Demonstrate skill in weighing himself or herself accurately and

recording weight.

• Measure and record own intake and output.

• Return to normal, appropriate diet.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Hydration;

Nutritional Status: Food & Fluid Intake; Risk Detection; Urinary

Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 4 hr. Fever, tachy-

cardia, dyspnea, or hypotension may indicate hypovolemia.

Determine patient’s fluid preferences to enhance intake.
Maintain accurate record of intake and output to aid estimation

of patient’s fluid balance. Measure urine output every hour. Record

and report output of less than ____ ml/hr. Decreased urine output

may indicate reduced fluid volume. Measure and record drainage

from all tubes and catheters to take such losses into account when

replacing fluid.

145
When copious drainage appears on dressings, weigh dressings

every 8 hr and record with other output sources. Excessive wound

drainage causes significant fluid imbalances (1 kg dressing equals

about 1 qt [1 L] of fluid).

Test urine specific gravity each shift. Monitor laboratory values

and report abnormal findings to physician. Increased urine specific

gravity may indicate dehydration. Elevated HCT and Hb levels also

indicate dehydration.

Monitor serum electrolyte levels and report abnormalities. Fluid

loss may cause significant electrolyte imbalance.

Obtain and record patient’s weight at same time every day to help

ensure accurate data. Daily weighing helps estimate body fluid status.

Monitor skin turgor each shift to check for dehydration; report

any decrease in turgor. Poor skin turgor is a sign of dehydration.

Examine oral mucous membranes each shift. Dry mucous

membranes are a sign of dehydration.

Perform: Cover wounds to minimize fluid loss and prevent skin

excoriation.

Keep oral fluids at bedside within patient’s reach and encourage

patient to drink. This gives patient some control over fluid intake

and supplements parenteral fluid intake.

Force oral fluids when possible and indicated to enhance replace-

ment of lost fluids. (Bowel sounds should be present and patient

awake before giving oral fluids.)

Administer parenteral fluids, as prescribed, to replace fluid losses.

Maintain parenteral fluids or blood transfusions at prescribed rate to

prevent further fluid loss or overload.

Progress patient to appropriate diet, as prescribed, to help achieve

fluid and electrolyte balance.

Inform: Instruct patient in maintaining appropriate fluid intake,

including recording daily weight, measuring intake and output, and

recognizing signs of dehydration. This encourages patient and care-

giver participation and enhances patient’s sense of control.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Fluid Management; Fluid Monitoring;

Hypovolemia Management; Hypovolemia Intravenous Therapy;

Hypovolemia Monitoring; Surveillance

Reference

Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is

needed in preventing, recognizing, and treating dehydration. American Jour-
nal of Nursing, 106(6), 40–49.

Nursing diagnosis – EXCESS FLUID VOLUME

EXCESS  FLUID  VOLUME

DEFINITION

Increased isotonic fluid retention

DEFINING CHARACTERISTICS

• Altered mental status or respiratory pattern

• Anasarca

• Azotemia

• Changes in blood pressure, pulmonary artery pressure, urine

specific gravity, and electrolyte levels

• Crackles

• Decreased Hb and HCT levels

• Dyspnea

• Edema

• Increased central venous pressure (CVP)

• Intake greater than output

• Jugular vein distention

• Oliguria

• Orthopnea

• Pleural effusion

• Positive hepatojugular reflex

• Pulmonary congestion

• Rapid weight gain

• Restlessness and anxiety

• S3 heart sound

RELATED FACTORS

• Compromised regulatory mechanism

• Excess fluid intake

• Excess sodium intake

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Elimination

• Nutrition

• Fluid and electrolytes

• Respiratory function

EXPECTED OUTCOMES

The patient will

• State ability to breathe comfortably.

• Maintain fluid intake at ___ ml/day.

• Return to baseline weight.

• Maintain vital signs within normal limits (specify).

• Exhibit urine specific gravity of 1.005–1.010.

• Have normal skin turgor.

• Show electrolyte level within normal range (specify).

• Avoid complications of excess fluid.

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SUGGESTED NOC OUTCOMES

Electrolyte Balance; Fluid Balance; Fluid Overload Severity; Kidney

Function; Nutritional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs at least every 4 hr.

Changes may indicate fluid or electrolyte imbalances. Measure and

record intake and output. Intake greater than output may indicate

fluid retention and possible overload.

Weigh patient at same time each day to obtain consistent

readings. Test urine specific gravity every 8 hr and record results.

Monitor laboratory values and report significant changes to

physician. High specific gravity indicates fluid retention. Fluid over-

load may alter electrolyte levels.

Assess patient daily for edema, including ascites and dependent or

sacral edema. Fluid overload or decreased osmotic pressure may

result in edema, especially in dependent areas.

Perform: Help patient into a position that aids breathing, such as

Fowler’s or semi-Fowler’s, to increase chest expansion and improve

ventilation.

Administer oxygen, as ordered, to enhance arterial blood oxygena-

tion. Restrict fluids to ____ ml per shift. Excessive fluids will worsen

patient’s condition.

Administer diuretics to promote fluid excretion. Record effects.

Maintain patient on sodium-restricted diet, as ordered, to reduce

excess fluid and prevent reaccumulation.

Reposition patient every 2 hr, inspect skin for redness with each

turn, and institute measures as needed to prevent skin breakdown.

Apply antiembolism stockings or intermittent pneumatic compres-

sion stockings to increase venous return. Remove for 1 hr every

8 hr or according to facility policy.

Inform: Educate patient regarding maintenance of daily weight

record, daily measuring and recording of intake and output, diuretic

therapy, and dietary restrictions, especially sodium. These measures

encourage patient and caregivers to participate more fully.

Attend: Encourage patient to cough and deep breathe every 2–4 hr

to prevent pulmonary complications.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management; Fluid Management; Fluid Monitoring;

Nutrition Management

Reference

Bennett, S. J., et al. (2005, December). Medication and dietary compliance

beliefs in heart failure. Western Journal of Nursing Research, 27(8),
977–993.

Nursing diagnosis – DEFICIENT FLUID VOLUME

DEFICIENT  FLUID  VOLUME

DEFINITION

Decreased intravascular, interstitial, or intracellular fluid; water loss

alone without change in sodium

DEFINING CHARACTERISTICS

• Changes in mental status

• Decreased pulse volume and pressure, urine output, and venous

filling

• Dry skin and mucous membranes

• Increased body temperature, HCT, pulse rate, and urine concen-

tration

• Low blood pressure

• Poor turgor of skin or tongue

• Sudden weight loss

• Thirst

• Weakness

RELATED FACTORS

• Active fluid volume loss

• Failure of regulatory mechanisms

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Have electrolyte levels within normal range.

• Maintain an adequate fluid volume.

• Maintain an adequate urine volume.

• Have normal skin turgor and moist mucous membranes.

• Have a urine specific gravity between 1.005 and 1.010.

• Have normal fluid and blood volume.

• Express understanding of factors that caused fluid volume deficit.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Hydration; Nutri-

tional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 2 hr or as often as

necessary until stable. Then monitor and record vital signs every

4 hr. Tachycardia, dyspnea, or hypotension may indicate fluid

volume deficit or electrolyte imbalance.

Measure intake and output every 1–4 hr. Record and report sig-

nificant changes. Include urine, stools, vomitus, wound drainage,

141

nasogastric drainage, chest tube drainage, and any other output.

Low urine output and high specific gravity indicate hypovolemia.

Weigh patient daily at same time to give more accurate and con-

sistent data. Weight is a good indicator of fluid status.

Assess skin turgor and oral mucous membranes every 8 hr to

check for dehydration. Give meticulous mouth care every 4 hr to

avoid dehydrating mucous membranes.

Test urine specific gravity every 8 hr. Elevated specific gravity may

indicate dehydration.

Measure abdominal girth every shift to monitor for ascites and

third-space shift. Report changes.

Perform: Cover patient lightly. Avoid overheating to prevent vasodi-

lation, blood pooling in extremities, and reduced circulating blood

volume.

Administer fluids, blood or blood products, or plasma expanders

to replace fluids and whole blood loss and facilitate fluid movement

into intravascular space. Monitor and record effectiveness and any

adverse effects.

Don’t allow patient to sit or stand up quickly as long as circula-

tion is compromised to avoid orthostatic hypotension and possible

syncope.

Administer and monitor medications to prevent further fluid loss.

Inform: Explain reasons for fluid loss, and teach patient how to

monitor fluid volume; for example, by recording daily weight and

measuring intake and output. This encourages patient involvement

in personal care.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Electrolyte Monitoring; Fluid Management;

Hypovolemia Management

Reference

Kelley, D. M. (2005, January–March). Hypovolemic shock: An overview. Crit-

ical Care Nursing Quarterly, 28(1), 2–19.

Nursing diagnosis – READINESS FOR ENHANCED FLUID BALANCE

READINESS  FOR  ENHANCED

FLUID  BALANCE

DEFINITION

A pattern of equilibrium between fluid volume and chemical compo-

sition of body fluids that is sufficient for meeting physical needs and

can be strengthened

DEFINING CHARACTERISTICS

• Verbalization of willingness to enhance fluid balance

• Stable weight

• Moist mucous membranes

• Food and fluid intake adequate for daily needs

• Straw-colored urine with specific gravity within normal limits

• Good tissue turgor

• No excessive thirst

• Urine output appropriate for intake

• No evidence of edema or dehydration

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Cardiac function

• Neurocognition

• Elimination

• Respiratory function

EXPECTED OUTCOMES

The patient will

• Have stable vital signs within normal ranges; electrocardiograph

shows no abnormality in rhythm.

• Have normal skin temperature, moistness, turgor, and color.

• Have moist and noncracked mucous membranes.

• Have stable weight.

• Have adequate fluid volume intake and thirst satiety.

• Produce adequate urine volume (approximately equal to fluid

intake) of light to straw-colored urine.

• Maintain a urine specific gravity between 1.015 and 1.025.

• Have normal values for plasma and serum for electrolytes, osmo-

larity, glucose, blood urea nitrogen, hematocrit (HCT), and hemo-
globin (Hb).

• Be alert and respond to demands of living; react appropriately to

reflex needs (i.e., thirst); have normal muscle reflexes, strength,
and tone.

• Express understanding of factors that contribute to normal fluid

and electrolyte balance.

• Adhere to prescribed therapies to manage such coexisting disease

processes.

SUGGESTED NOC OUTCOMES

Fluid Balance; Hydration; Nutritional Status: Food & Fluid Intake;

Tissue Integrity: Skin & Mucous Membranes; Vital Signs

139

INTERVENTIONS AND RATIONALES

Determine: Assess usual fluid intake and desire to improve fluid sta-

tus to establish a baseline.

Inform: Teach patient to read and interpret labels on beverage and

food containers. For example, humans require 0.5 g (500 mg) of

sodium per day; typical intake is 5–6 g daily. Reducing the amount

of sodium reduces the amount of fluid volume in the vascular

system.

Encourage adequate water intake (1,200–2,000 ml) during

exercise or high environmental temperatures; unmeasured fluid losses

through diaphoresis and lung evaporation can be significant.

Teach signs and symptoms of dehydration (dry mouth and

mucous membranes), light-headedness (blood pressure and vital sign

changes), scant urine output (glycosuria and polyuria), and over-

hydration (cough, increased weight gain, dependent edema, and

jugular vein distention). Teaching prevents severe complications.

Attend: Encourage patient to select healthy beverages such as water

and limit beverages such as soda or sports drinks that have high

sugar content (which increase the osmolar content of the body, caus-

ing greater thirst and increased load on the renal system and diuresis)

and caffeine (which causes diuresis and may cause an increased fluid

loss), alcoholic beverages during hot weather because these can

cause fluid and electrolyte disturbances through excess diuresis.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management; Fluid/Electrolyte Management; Fluid Man-

agement; Fluid Monitoring

Reference

Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is

needed in preventing, recognizing, and treating dehydration. American Journal
of Nursing, 106(6), 40–49.

Nursing diagnosis – FEAR

FEAR

DEFINITION

Response to a perceived threat that is consciously recognized as a

danger

DEFINING CHARACTERISTICS

• Behaviors involving aggression, avoidance, impulsivness, increased

alertness, and narrowed focus of the source of fear

• Cognitive effects such as decreased self-assurance, productivity, and

ability to problem solve

• Feelings of alarm, apprehension, increased tension, panic, and terror

• Physiological changes including increased heart rate, respiration

rate, perspiration, and/or blood pressure; anorexia, nausea, vomit-
ing, diarrhea, muscle tightness, fatigue, and shortness of breath
and pallor

RELATED FACTORS

• Language barrier

• Separation from support

• Learned response

system

• Phobic stimulus

• Unfamiliarity with

• Sensory impairment

environmental experience

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Risk management

• Coping

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Identify source of fear.

• Communicate feelings about separation from support systems.

• Communicate feelings of comfort or satisfaction.

• Use situational supports to reduce fear.

• Integrate into daily behavior at least one fear-reducing coping

mechanism, such as asking questions about treatment progress or
making decisions about care.

SUGGESTED NOC OUTCOMES

Anxiety Control; Comfort Level; Coping; Fear Control; Pain Level

INTERVENTIONS AND RATIONALES

Determine: Ask patient to identify source of fear; assess patient’s

understanding of situation. Perceptions may be erroneously based.

Perform: Help patient maintain daily contact with family: Arrange

for telephone calls; help write letters; promptly convey messages to

patient from family and vice versa; encourage patient to have

pictures of loved ones; provide privacy for visits; take patient to day

room or other quiet area. These measures help patient reestablish

and maintain social relationships.

137
Involve patient in planning care and setting goals to renew confi-

dence and give a sense of control in a crisis situation. If patient has

no visitors, spend an extra 15 min each shift in casual conversation;

encourage other staff members to stop for brief visits. These meas-

ures help patient cope with separation.

Administer antianxiety medications, as ordered, and monitor effec-

tiveness. Drug therapy may be needed to manage high anxiety levels

or panic disorders.

Inform: Instruct patient in relaxation techniques such as imagery and

progressive muscle relaxation to reduce symptoms of sympathetic

stimulation.

Answer questions and help patient understand care to reduce anx-

iety and correct misconceptions.

Attend: When feasible and where policies permit, relax visiting

restrictions to reduce patient’s sense of isolation.

Allow a close family member or friend to participate in care to

provide an additional source of support.

Support family and friends in their efforts to understand patient’s

fear and to respond accordingly to help them understand that

patient’s emotions are appropriate in context of situation.

Manage: Refer patient to community or professional mental health

resources to provide assistance.

SUGGESTED NIC INTERVENTIONS

Active Listening; Anxiety Reduction; Cognitive Restructuring; Coun-

seling; Coping Enhancement; Decision-Making Support; Security

Enhancement; Presence; Support Group

Reference

Cookman, C. (2005, June). Attachment in older adulthood: Concept clarifica-

tion. Journal of Advanced Nursing, 50(5), 528–535.

Nursing diagnosis – FATIGUE

FATIGUE

DEFINITION

An overwhelming sustained sense of exhaustion and decreased

capacity for physical and mental work at usual level

DEFINING CHARACTERISTICS

• Decreased libido or performance

• Disinterest in surroundings

• Drowsiness

• Failure of sleep to restore energy

• Lack of energy

• Guilt for not meeting responsibilities

• Inability to maintain usual routines

• Impaired concentration

• Increased need for rest

• Increased physical complaints

• Lethargy or listlessness

• Perceived need for more energy for routine tasks

• Verbalization of overwhelming lack of energy

RELATED FACTORS

• Psychological, e.g., anxiety,

• Environmental, e.g., humidity,

depression, stress

lights, noise, temperature

• Physiological, e.g., anemia, dis-

• Situational, e.g., negative life

ease states, malnutrition, preg-
nancy, poor physical condition

events, occupation

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Reproduction

• Cardiovascular function

• Respiratory function

• Coping

• Risk management

• Neurocognition

• Sleep/rest

• Nutrition

EXPECTED OUTCOMES

The patient will

• Identify and employ measures to prevent or modify fatigue.

• Explain relationship of fatigue to disease process and activity level.

• Verbally express increased energy.

• Articulate plan to resolve fatigue problems.

SUGGESTED NOC OUTCOMES

Activity Tolerance; Endurance; Energy Conservation; Nutritional Sta-

tus: Energy; Psychomotor Energy; Personal Well-Being

INTERVENTIONS AND RATIONALES

Determine: Assess usual patterns of sleep and activity to establish a

baseline.

135

Perform: Conserve energy through rest, planning, and setting priori-

ties to prevent or alleviate fatigue. Alternate activities with periods

of rest. Avoid scheduling two energy-draining procedures on the

same day. Encourage activities that can be completed in short peri-

ods. These measures help to avoid overexertion and increase stamina.

Reduce demands placed on patient (e.g., ask one family member

to call at specified times and relay messages to friends and other

family members) to reduce physical and emotional stress.

Structure environment (e.g., set up daily schedule on the basis of

patient needs and desires) to encourage compliance with treatment

regimen.

Postpone eating when patient is fatigued, to avoid aggravating

condition. Provide small, frequent feedings to conserve patient’s

energy and encourage increased dietary intake.

Establish a regular sleeping pattern. Getting 8–10 hr of sleep

nightly helps reduce fatigue.

Inform: Discuss effect of fatigue on daily living and personal goals.

Explore with patient relationship between fatigue and disease

process to help increase patient compliance with schedule for activ-

ity and rest.

Attend: Encourage patient to eat foods rich in iron and minerals,

unless contraindicated to help avoid anemia and demineralization.

Manage: Encourage patient to explore feelings and emotions with a

supportive counselor, clergy, or other professional to help cope with

illness and avoid aggravating fatigue.

SUGGESTED NIC INTERVENTIONS

Activity Therapy; Coping Enhancement; Energy Management;

Exercise Promotion; Sleep Enhancement

Reference

Barsevick, A. M., et al. (2006, September–October). Cancer-related fatigue,

depressive symptoms, and functional status: A mediation model. Nursing
Research, 55(5), 366–372.

Nursing diagnosis – READINESS FOR ENHANCED FAMILY PROCESSES

READINESS  FOR  ENHANCED

FAMILY  PROCESSES

DEFINITION

A pattern of family functioning that is sufficient to support the well-

being of family members and can be strengthened

DEFINING CHARACTERISTICS

• Activities support the growth of family members

• Activities support the safety of family members

• Balance exists between autonomy and cohesiveness

• Boundaries of family members are maintained

• Energy level of family supports ADLs

• Family adapts to change

• Relationships are generally positive

• Respect for family members is positive

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Roles/relationship

• Coping

• Communication

• Values/beliefs

EXPECTED OUTCOMES

Family members will

• Identify family goals and structured directions.

• Express enjoyment and satisfaction with their roles in the family.

• Express a willingness to enhance roles in family dynamics.

• Participate regularly in traditional family activities.

• Maintain open and positive communication.

• Maintain a safe home environment.

• Seek regular health screenings and immunizations.

• Identify and acknowledge family risk factors.

• Make plans to deal with life changes and events.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Health Status; Family

Integrity; Family Normalization; Family Social Climate

INTERVENTIONS AND RATIONALES

Determine: Assess family composition, roles within the family,

communication patterns, family developmental stages, developmen-

tal tasks, health patterns, coping mechanisms, socioeconomics,

educational levels, ethnicity, and cultural and religious beliefs.

Assessment information helps identify appropriate interventions.

Perform: Establish an environment in which family members can

openly share their issues and concerns in comfort to reduce anxiety

and develop their ability to resolve problems.

Inform: Explain importance of setting goals as a method of estab-

lishing boundaries that will be respected by all family members.

Family functioning with structural direction will enhance the poten-

tial to meet physical, social, and psychological needs.

133
Show family how to develop a Genogram to identify genetic risk

factors. Information from the Genogram will highlight things that

can modify a family’s health patterns, lead to early identification of

genetically related diseases, and may delay onset of disease.

Teach value of daily exercise, well-balanced diet, and use of

proven holistic strategies to improve health.

Provide family with information on recommended health screen-

ings and immunization schedules. It is essential to keep immuniza-

tions given according to schedule to prevent loss of immunity.

Attend: Encourage family members to identify individual and family

goals and a structured direction toward sound health habits for the

entire family. Developing a structured plan will assist in having

everyone work together toward goals set by the family for

themselves.

Involve family in planning and decision making. Having the abil-

ity to participate encourages greater compliance with the plan.

Encourage family to spend time together enjoying traditional

activities that everyone likes doing to promote a healthy lifestyle and

encourage strong family unity.

Manage: Refer, where requested, for follow-up for a family member

who needs exercise, weight management, diet assistance, health

screenings, and so forth. Providing referrals will help to provide

continuity of care for the patient.

SUGGESTED NIC INTERVENTIONS

Family Support; Family Integrity Promotion; Family Maintenance

Reference

Yanaka, L., et al. (2007, January–February). Barriers to screening for domestic

violence in the emergency departments. Journal of Continuing Education in
Nursing, 38(1), 37–45.

Nursing diagnosis – INTERRUPTED FAMILY PROCESSES

INTERRUPTED  FAMILY  PROCESSES

DEFINITION

Change in family relationship or functioning

DEFINING CHARACTERISTICS

Changes in:

• Assigned tasks

• Availability for affective responses and/or emotional support

• Communication patterns

• Effectiveness in completing assigned tasks

• Expressions of conflict within family and/or community resources

• Expressions of isolation from community resources

• Intimacy

• Participation in problem solving and/or decision making

• Stress-reduction behaviors

RELATED FACTORS

• Developmental crises

• Modification in family finances

• Developmental transition

• Modification in family social

• Family role shift

status

• Interaction with community

• Situational transition

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Emotional

• Coping

• Roles/relationship

EXPECTED OUTCOMES

Family members will

• Not experience physical, verbal, emotional, or sexual abuse.

• Communicate clearly, honestly, consistently, and directly.

• Establish clearly defined roles and equitable responsibilities.

• Express understanding of rules and expectations.

• Report the methods of problem solving and resolving conflicts

have improved.

• Report a decrease in the number and intensity of family crises.

• Seek ongoing treatment.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Normalization; Social

Interaction Skills; Substance Addiction Consequences

INTERVENTION AND RATIONALES

Determine: Assess family’s developmental stage, roles, rules, socioeco-

nomic status, health history, history of substance abuse; history of sex-

ual abuse of spouse or children, problem-solving and decision-making

131

skills, and patterns of communication. Assessment information will

provide development of appropriate interventions.

Perform: Meet with family members to establish levels of authority

and responsibility in the family. Understanding the family dynamics

provides information about the kinds of support the family needs to

work with the patient’s issues.

Create an environment in which family members can express

themselves openly and honestly to build trust and self-esteem.

Establish rules for communication during meetings with the family

to assist family members to take responsibility for their own behavior.

Inform: Teach family members basic communication skills to enable

them to discuss issues in a positive way. Have them role-play with

one another numerous times to demonstrate what has been learned.

Involve the family in exercises to reduce stress and deal with

anger.

Attend: Hold adults accountable for their alcohol or substance abuse

and have them sign a “Use contract” to decrease denial, increase

trust, and promote positive change.

Involve patient in planning and decision making. Having the abil-

ity to participate will encourage greater compliance with the plan.

Assist family to set limits on abusive behaviors and have them

sign “Abuse contracts” to foster feelings of safety and trust.

Manage: Refer to case manager/social worker to ensure that a home

assessment is done.

Refer to support groups that deal with substance abuse, domestic

violence, or sexual abuse depending on the needs of the patient

and/or family to enhance interpersonal skills and strengthen the fam-

ily unit.

Provide all appropriate phone numbers so that the family

members can initiate whatever follow-up is needed.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Family Integrity Promotion; Family Process

Maintenance; Family Support; Normalization Promotion; Substance

Use Prevention; Substance Use Treatment

Reference

Yonaka, L., et al. (2007, January–February). Barriers to screening for domestic

violence in the emergency department. Journal of Continuing Education for
Nursing, 38(1), 37–45.

Nursing diagnosis – DYSFUNCTIONAL FAMILY PROCESSES ALCOHOLISM

DYSFUNCTIONAL  FAMILY  PROCESSES:

ALCOHOLISM

DEFINITION

Psychosocial, spiritual, and physiological functions of the family unit

are chronically disorganized, which leads to conflict, denial of prob-

lems, resistance to change, ineffective problem solving, and a series

of self-perpetuating crises

DEFINING CHARACTERISTICS

• Alcohol abuse; agitation; blaming; broken promises

• Deficient knowledge about alcoholism

• Denial of problems; difficulty with intimate relationships

• Enabling to maintain alcoholic drinking pattern

• Rationalization; moodiness; rejection; tension

• Triangulating family relationships

• Marital problems; ineffective spousal communication

RELATED FACTORS

• Abuse of alcohol

• Family history of alcoholism

• Addictive personality

• Family history of resistance to

• Biochemical influences

treatment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Communication

• Emotional

• Knowledge

• Coping

• Self-perception

• Values and beliefs

EXPECTED OUTCOMES

Family members will

• Acknowledge there is a problem with alcoholism within the family.

• Sign contracts stating they will not engage in abusive behavior.

• Communicate their needs, using “I” statements.

• Discuss problems in an open, safe environment.

• Acknowledge their strengths and progress in resolving problems.

• State plans to continue to seek counseling and attend appropriate

support group meetings.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Normalization; Role

Performance; Substance Abuse Consequences

INTERVENTIONS AND RATIONALES

Determine: Assess drinking pattern; use of other substances; patterns

of withdrawal; ability of alcoholic member to function in

occupational and familial roles; ability of family members to func-

tion in their roles; family health history; affiliation with a religious

group and religious practices. Assessment factors will assist in identi-

fying appropriate interventions.

Perform: Create an environment in which family members feel free

to express themselves honestly about the present situation to

129

decrease their anxiety and help family members develop confidence

in their ability to resolve problems.

Inform alcoholic family member that he will have to acknowledge

his alcoholism before progress can be made in rebuilding family

relations to establish abstinence as a basis for treatment.

Inform: Teach family members to communicate their needs

assertively. Have them practice using “I” statements to express feel-

ings to help them get in touch with their feelings.

Inform patient and family about the symptoms and effects of addic-

tive behaviors on both the patient and the family to help them under-

stand the role they play in both the disease and the recovery process.

Do interactive planning and role-playing with the patient and

family to help them gain the skills needed to effect necessary

changes in communication patterns in the family. Role-playing helps

create a realistic view of the behaviors that reinforce behaviors in

themselves and the patient.

Attend: Encourage family members to acknowledge that alcoholism is

a problem within the family in order to break through family denial.

Ask alcoholic family member to sign a contract stating he will

abstain from alcohol to help him take responsibility for his own

behavior.

Help family members evaluate the consequences of abusive and vio-

lent behavior. Inform them that any suspected abuse will be reported.

Ask family members to sign contracts so they will not continue to

abuse one another to make them take responsibility for their behavior.

Being able to identify strengths provides the confidence the family

needs to continue working toward a positive outcome for both

patient and family.

Assist family members to identify their strengths and talk about

progress they have made in resolving problems associated with alco-

holism or living with a family member who has alcoholism.

Provide additional emotional support to the head of the family

about altered role and additional responsibility to build self-esteem.

Manage: Refer family for continued family therapy so they can con-

tinue the process of restructuring their lives.

Refer patient and family to AA, Alanon, or other appropriate sup-

port group to establish the importance of abstinence.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Family Process Maintenance; Family Support;

Substance Use Prevention; Substance Use Prevention

Reference

Fowler, T. L. (2006, July). Alcohol dependence and depression: Advanced

nursing interventions. Journal of the American Academy of Nurse
Practitioners, 18(7), 303–308.

Nursing diagnosis – RISK FOR FALLS

RISK  FOR  FALLS

DEFINITION

Increasing susceptibility to falling that may cause physical harm

RISK FACTORS

Adult

• Patient verbalizes faintness

• Age   65 years

when extending neck

• Lives alone

• Difficulties with hearing or

• Environmental hazards (e.g.,

vision

cluttered environment; poor
lighting)

• Incontinence
Child

• Presence of lower limb pros-

• Age   2 years

thesis; use of assistive devices
for walking

• Environmental hazards (e.g.,
bed located near window, lack

• Has history of falls

of gate on stairs)

• Use of alcohol, diuretics, and

• Lack of parental supervision

tranquilizers

• Unattended infant on elevated

• Presence of anemias, diarrhea

surface (e.g., bed/changing table)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Sensation/perception

• Knowledge

EXPECTED OUTCOMES

Patient and family will

• Identify factors that increase potential for falling.

• Assist in identifying and applying safety measures to prevent injury.

• Make necessary changes in the physical environment to ensure

safety for the patient.

• Develop long-term strategies to promote safety and prevent falls.

• Optimize patient’s ability to carry out ADLs within sensor motor

limitations.

SUGGESTED NOC OUTCOMES

Ambulation; Balance; Cognition; Neurological Status; Risk Control;

Sensory Function: Vision; Sensory Function: Hearing

INTERVENTIONS AND RATIONALES

Determine: For adults, assess severity of sensory or motor deficits;

environmental hazards, and inadequate lighting; medication use;

improper use of assistive devices.

For children, assess sensory or motor deficits, recent illnesses,

unsteady balance, running at speeds beyond capability, and

inadequate supervision. Assessment factors will help identify appro-

priate interventions.

Perform: For older adults, make necessary changes in environment

(i.e., remove throw rugs). Orient patient to environment. Post a

127

notice that the patient is at risk for falling. Place side rails up and

bed position down when the patient is in bed. Place personal items

within the patient’s reach. These measures prevent injury to patient.

For children, make necessary changes in environment (i.e., apply

window guards); keep toys and other objects from lying around on

the floor; use a gate when necessary to keep the child in a confined

area; provide adequate supervision to prevent injury to the patient.

Inform: Provide family with a list of all the things they need to do

to prevent the patient from falling. Go over each item and explain

the reason for each cautionary measure. Written instructions will

reinforce the need for prevention.

Teach patient with an unstable gait how to use assistive devices

properly. Improper use of assistive devices can put the patient at

greater risk of falling.

Teach patient and family about the use of safe lighting. Advise

patients to wear sunglasses to reduce glare. Proper lighting is always

considered as a preventive measure.

Teach patient about medications that have been prescribed for

him or her. Overmedication in older adults is one of the major risk

factors in falls. Understanding on the part of the patient and family

can reduce the incidence of falls in the home.

Attend: Ask frequently during hospitalization whether patient and

family have questions about the modifications needed to prevent

falls. Listen carefully to statement or ideas the patient and/or family

may present about potential for falls in their individual home

settings. Greater awareness on the part of both patient and family

can markedly reduce the risk of falls.

Encourage adult patient to express feelings about the fear of falling.

Being able to express the fear will raise the nurse’s awareness of

what the patient considers problem areas.

Manage: Arrange for social service/case manager to make a home

visit to help prepare the family for the patient’s return to a safe

environment.

Refer patient and family to community resources that may offer

assistance to the patient when needed.

Refer to home health nurse for a follow-up visit in the home.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Exercise Therapy: Balance; Fall Preven-

tion; Medication Management; Teaching

Reference

Bright, L. (2005, January). Strategies to improve the patient safety outcome

indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1), 29–36.

Nursing diagnosis – ADULT FAILURE TO THRIVE

ADULT  FAILURE  TO  THRIVE

DEFINITION

Progressive functional deterioration of a physical and cognitive

nature. The individual’s ability to live with multisystem diseases,

cope with ensuing problems, and manage his/her care are remarkably

diminished

DEFINING CHARACTERISTICS

• Cognitive decline, as evidenced by problems with responding

appropriately to environmental stimuli and decreased
perception

• Consumption of limited to no food at most meals (i.e., consumes

less than 75% of normal replacements); weight loss

• Decreased participation in ADLs that were once enjoyed

• Decreased social skills or social withdrawal

• Difficulty performing simple self-care tasks

• Frequent exacerbations of chronic health problems, such as pneu-

monia or urinary tract problems

• Neglect of home environment or financial responsibilities

• Adequate elimination pattern for age

RELATED FACTOR

• Depression

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Knowledge

• Nutrition

• Coping

• Sleep patterns

• Emotional

• Values and beliefs

EXPECTED OUTCOMES

The patient will

• Express understanding of causes of failure to thrive.

• Express realization that he or she is depressed.

• Consume sufficient amounts of food and nutrients.

• Sleep for ___ hours without interruption.

• Gain weight.

• Verbalize feelings of safety.

• Follow up with psychiatric evaluation/social service assistance.

SUGGESTED NOC OUTCOMES

Nutritional Status: Physical Aging Status; Psychosocial Adjustment:

Life Change; Will to Live

INTERVENTIONS AND RATIONALES

Determine: Assess daily food intake; meal preparation; sleep

patterns; mobility status; education, activity, and exercise;

religious affiliation; involvement in social activities; and access to

transportation. Assessment factors will help identify appropriate

interventions.

125
Monitor fluids and electrolytes. Imbalance can be life-threatening.

Perform: Record daily weights at the same time each day to provide

consistent information.

Report abnormal electrolyte levels to ensure that therapy will

reverse and levels will not deteriorate.

Monitor fluid intake and output every 8 hr to ensure that fluids

are balanced. Imbalance can lead to heart failure or dehydration.

Record amount of food consumed and supplements given to

patient to ensure that the patient is getting sufficient nutrition.

Plan activities and exercise consistent with patient’s capabilities. It

is important that the patient be able to enjoy activity. Overexertion

can lead to cardiac problems.

Arrange for social interaction with other patients. Arrange for the

nurse to spend several short periods of uninterrupted time with the

patient each day to instill trust and a sense of caring.

Teach caregiver how to make meals that may be appetizing to the

patient. Encourage caregiver to record food consumed by patient.

Appetizing foods may help motivate the patient to eat when he or

she claims not to be hungry.

Attend: Create a pleasant mealtime environment for patient. Provide

unlimited access to nourishing foods and nutritional supplements.

Attempt to accommodate ethnic food preferences. This will encour-

age patient when he or she is hungry rather than when food is put

in front of him or her.

Encourage family members and caregivers to establish a plan for

addressing patient’s failure to thrive in order to take responsibility

for meeting the patient’s needs to the extent they are able.

Encourage patient to participate in active exercise during the day

to the extent he or she is able. Exercise is essential to a feeling of

well-being.

Manage: Refer patient and family to appropriate agencies in the

community such a meal programs, senior support/activities groups,

and so forth. This kind of follow-up will ensure that the plan has a

chance of succeeding.

Refer patient and family to social services for appropriate resources.
Refer to clergy person for spiritual help if patient wishes.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Home Maintenance Assistance; Nutritional

Monitoring; Spiritual Support

Reference

Lennie, T. A. (2006, March–April). Factors influencing food intake in patients

with heart failure: A comparison with healthy elders. The Journal of Car-
diovascular Nursing, 21(2), 123–129.

Nursing diagnosis – IMPAIRED ENVIRONMENTAL INTERPRETATION SYNDROME

IMPAIRED  ENVIRONMENTAL

INTERPRETATION  SYNDROME

DEFINITION

Consistent lack of orientation to person, place, time, or

circumstances over more than 3 to 6 months necessitating a

protective environment

DEFINING CHARACTERISTICS

• Chronic confusion

• Consistent state of disorientation to environment

• Inability to reason, concentrate, or follow simple instructions

• Loss of occupation or social function resulting from memory decline

• Slow response to questions

RELATED FACTORS

• Dementia

• Depression

• Huntington’s disease

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Communication

• Sensory perception

EXPECTED OUTCOMES

The patient will

• Acknowledge and respond to efforts by others to establish

communication.

• Identify physical changes without making disparaging comments.

• Remain oriented to the environment to the fullest possible extent.

• Remain free from injuries.

The caregiver will

• Describe measures for helping the patient cope with disorientation.

• Demonstrate reorientation techniques.

• Describe ways to make sure that the home is safe for the patient.

• Identify and contact appropriate support services for the patient.

SUGGESTED NOC OUTCOMES

Cognitive Orientation; Concentration; Fall-Prevention Behavior;

Memory; Safe Home Environment

INTERVENTIONS AND RATIONALES

Determine: Assess cultural status, functional ability and coordination,

interaction with others in social settings, and presence of vision or

hearing deficits. Assessment of these factors will help in identifying

appropriate interventions.

Perform: Orient patient to reality, as needed: call patient by name;

tell patient your name; provide day, date, year, and place; place a

photograph or patient’s name on the door; keep all items in the

same place. Consistency and continuity will reduce confusion and

decrease frustration.

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Place patient in a room near the nurse’s station to provide imme-

diate assistance from staff, if needed.

Clear patient’s room of any hazardous materials, and accompany

patient who wanders to prevent injury.

Work with patient and caregivers to establish goals for coping

with disorientation. Practice with coping skills can prevent fear.

When speaking to the patient, face him and maintain eye contact

to foster trust and communication.

Promote independence while performing ADL measures patient is

unable to perform to reduce feelings of dependence.

Inform: Provide written information to caregivers on reorientation

techniques. Demonstrate reorientation techniques to caregiver to

prepare caregiver to cope with the patient when he or she returns

home.

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

that maximizes patient’s potential to encourage patient’s independence.

Attend: Be attentive to the patient when you are with him. Be aware

that patient may be sensitive to your unspoken feelings about him in

order to inspire confidence in the caregiver.

Help patient and caregivers cope with feelings associated with the

disease. Understanding promotes affective coping.

Have patient perform ADLs. Begin slowly and increase daily, as

tolerated to assist patient to regain independence and enhance self-

esteem. Provide reassurance and praise for completing simple tasks.

Focus on patient’s strengths.

Involve caregiver and patient in planning and decision making as

a cooperative effort supports patient’s needs.

Encourage patient to engage in social activities with people of

all age groups once a week to help relieve the patient’s sense of

isolation.

Manage: Refer patient to case manager/social worker to ensure

that patient receives longer term assistance to ensure continued

care.

Refer caregiver to a support group. Caregivers need continuous

support from others to cope with the need to provide constant

supervision to the patient.

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction; Behavior Management; Dementia Management;

Emotional Support; Mood Management; Reality Orientation

Reference

Patton, D. (2006). Reality orientation: Its use and effectiveness within older

person health care. Journal of Clinical Nursing, 15(11), 440–449.

Nursing diagnosis – DISTURBED ENERGY FIELD

DISTURBED  ENERGY  FIELD

Disruption of the flow of energy surrounding a person’s being that

results in disharmony of body, mind, and/or spirit

DEFINING CHARACTERISTICS

Perceptions of changes in patterns of energy flow, such as changes in

• Hearing (tones, words).

• Perception of movement (wave spike, tingling, dense, flowing).

• Temperature.

• Sight (image, color).

RELATED FACTORS

Factors secondary to the slowing or blocking of energy flows may

be as follows:

• Maturational (age-related devel-

• Situational (anxiety, fear, griev-

opmental crisis and/or develop-
mental [mental] difficulties)

ing, and pain)
• Treatment-related (chemother-

• Pathophysiologic (illness,

apy, immobility, labor & deliv-

injury, and pregnancy)

ery, perioperative experience)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional status

• Coping

• Sensation/perception

EXPECTED OUTCOMES

The patient will

• Feel increasingly relaxed by slower and deeper breathing, skin

flushing in treated area, audible sighing, or verbal reports of feel-
ing more relaxed.

• Visualize images that relax him.

• Report feeling less tension or pain.

• Use self-healing techniques such as meditation, guided imagery,

yoga, and prayer.

SUGGESTED NOC OUTCOMES

Comfort Level; Health Beliefs; Personal Health Status; Personal

Well-Being; Spiritual Health

INTERVENTIONS AND RATIONALES

Determine: Assess how much support patient desires. Evaluate the

presence of a disorder that is life threatening or requires surgery.

Monitor levels of pain and disorders that may affect the senses.

Assess patient’s spiritual needs, including religious beliefs and affilia-

tion. Assessment of these areas will help to identify appropriate

interventions.

Perform: Implement measures to promote therapeutic healing. Place

your hands 4   to 6   above the patient’s body. Pass hands over the

entire skin surface to become intoned to the patient’s energy fields,

which is the flow of energy that surrounds the human being. Identify

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areas where there is energy disturbance considering cues such as

cold, heat, tingling, and electric sensation. This technique helps you

become attuned to patient’s energy field, the flow of energy that sur-

rounds a person’s being.

Administer medication as ordered to relieve pain.
Turn and reposition patient at least every 2 hr. Establish a turning

schedule for the dependent patient. Post schedule at bedside and

monitor frequency. Turning and repositioning prevent skin

breakdown, improve lung expansion, and prevent atelectasis.

Provide comfort measures such as bathing, massage, regulation of

environmental temperature, and mouth care, according to the

patient’s preferences. Comfort measures done for and with the

patient reduce anxiety and promote feelings of well-being.

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

(e.g., meditation, guided imagery, yoga, and prayer). Teach patient

how to incorporate the use of self-healing techniques in carrying out

usual daily activities. It will take repeated use of strategies to induce

a spirit of well-being.

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

that maximizes his or her comfort. Caregivers may need assistance

with techniques. Lack of skill can cause the patient unnecessary

pain.

Attend: Encourage patient’s cooperation as you continue with heal-

ing techniques, such as therapeutic touch. Listen for evidence of

effectiveness of treatment by patient’s statements about reduction in

tension or pain. One treatment rarely restores a full sense of well-

being.

Manage: Refer to mental health specialist or other community agen-

cies as needed. It is important for patient to have ongoing support.

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

Therapeutic Touch; Discharge Planning; Anxiety Reduction; Pain

Management

Reference

Robb, W. J. (2006, April–June). Self-healing: A concept analysis. Nursing

Forum, 41(2), 60–77.

Nursing diagnosis – RISK FOR ELECTROLYTE IMBALANCE

RISK  FOR  ELECTROLYTE  IMBALANCE

DEFINITION

At risk for change in serum electrolyte levels that may compromise

health

RISK FACTORS

• Fluid imbalance (e.g., dehydra-

• Renal dysfunction

tion, water intoxication)

• Endocrine dysfunction

• Treatment-related side effects

• Impaired regulatory mechanisms

(e.g., medications, drains)

(e.g., diabetes insipidus, syn-

• Diarrhea

drome of inappropriate

• Vomiting

antiduretic hormone (SIADH))

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain electrolyte levels within the normal limits.

• Maintain adequate fluid balance consistent with underlying disease

restrictions.

• Identify health situations that increase risk for electrolyte

imbalance and verbalize interventions to promote balance.

• Verbalize signs and symptoms that require immediate intervention

by healthcare provider.

• Remain safe from injury associated with electrolyte imbalance.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance, Fluid Balance

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s fluid status. Patients who demonstrate

fluid volume alterations are likely to have electrolyte alterations as

well.

Monitor patient for physical signs of electrolyte imbalance. Many

cardiac, neurological, and musculoskeletal symptoms are indicative

of specific electrolyte abnormalities.

Perform: Collect and evaluate serum electrolyte results as ordered to

allow for prompt diagnosis and treatment of any abnormalities.

Treat underlying medical condition. Correction of the underlying

cause of electrolyte imbalance is the first step in correcting

electrolyte imbalance.

Inform: Educate patient and family regarding risks for electrolyte dis-

turbances associated with their particular medical condition and pos-

sible interventions if symptoms occur. Early identification and inter-

vention may prevent life-threatening complications of electrolyte

imbalance.

119

Attend: Provide support and encouragement to patient and family in

their efforts to participate in the management of the condition. Pos-

itive feedback will increase self-confidence and feeling of partnership

in care.

Manage: Coordinate care with other members of the healthcare team

to provide safe environment. Electrolyte imbalances can cause poor

coordination, weakness, and altered gait.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management, Electrolyte Monitoring, Fluid–Electrolyte

Management

Reference

Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled

water. Journal of Perianesthesia Nursing, 23, 267–272.